Most health professionals are reluctant to report errors, fearing a punitive hospital culture, according to a recent Agency for Healthcare Research and Quality (AHRQ) report.
Out of the more than half a million survey respondents from 1,128 hospitals, nearly half of the staff said that they feel their mistakes and event reports are being held against them, American Medical News reported. Nearly two-thirds said they think their mistakes are kept in their personnel file, and 54 percent said when an adverse event is reported, "it feels like the person is being written up, not the problem."
"You could see how the traditional approach--an event is reported and someone is written up--has a hall monitor in elementary school feeling to it," said patient safety advocate and hospitalist leader Bob Wachter, chief of the medical service at the University of California, San Francisco Medical Center. "It's extraordinarily destructive in a patient safety context."
Coupled with the fact that 86 percent of hospital workers don't report patient harm events, the AHRQ survey may prove to be disappointing news to patient safety advocates who have championed transparency and a blame-free hospital culture.
A Health and Human Services Department Office of Inspector General report last month, however, found that the reason for unreported events had to do more with staff misunderstanding of what events are reportable. The OIG recommends AHRQ and the Centers for Medicare & Medicaid Services join forces to enhance the efficiency of incident reporting systems.
AHRQ also suggested that its survey isn't an end-all-be-all, but rather just the beginning. The agency encourages hospitals to create an action plan for patient safety improvement, including communicating the plan and tracking progress, as well as sharing best practices of what actually works.
For more information:
- read the amednews article
- check out the AHRQ report
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