Fear of retribution. “You have to feel safe to report someone else’s error, or your own,” Gibson said. “Most hospitals have yet to create a safety culture.”
Explore This IssueApril 2012
A sense of disbelief. “I remember talking to a hospital CEO once right after the IOM report,” Gibson said. “He said that after a significant error, he would get up in the morning and look in the mirror and think, ‘Did this really happen here?’ There’s almost a sense that if you don’t see it, it didn’t exist.”
Competing pressures. “The requirements of health care reform have taken up so much time and energy that I fear safety has moved to the back burner,” Gibson said. “Someone in a quality and safety leadership role at one hospital said to me, ‘Safety was just a fad. We’re not doing that anymore.’”
Productivity demands. “Health care’s mantra today has become volume, volume, volume. If you already have an environment that’s not as safe as we would like, and you ramp up the volume so people have to do more in the name of productivity, what’s going to happen?” Gibson said.
Adding to these problems is the fact that most hospital systems, like the legal system, contain no incentives to report errors—if anything, the incentives are stacked in the other direction, said Rahul Shah, MD, associate surgeon-in-chief and associate professor of otolaryngology and pediatrics at Children’s National Medical Center in Washington, DC. “On a hospital level, the medical staff will scrutinize you. There’s professional liability. There’s your reputation. Currently, there’s no positive incentive to report other than doing the right thing.”
Dr. Shah is the author of the only study to date to have collected data on errors in otolaryngology and classified them into the realms of pre-operative, operative, and post-operative care. Published in 2004, this study suggested that there may be as many as 2,600 episodes of major morbidity and approximately 165 deaths annually attributable to preventable errors in otolaryngology (Laryngoscope. 114(8):1322-1335).
“In pre-operative care, we find that the biggest cause of preventable errors is not getting all your consults ready before proceeding with surgery,” Dr. Shah says. “During the operative phase, technical errors are predominant. That makes perfect sense: We’re a surgical specialty. You need redundancy of equipment when possible, as well as technical representatives for such equipment.”
Post-operative errors in otolaryngology, Dr. Shah said, largely involve medications. “I’m a pediatric otolaryngologist and I prescribe only five or six medications, but even with that you’ll get dosage errors. I pause and take a moment to reorient myself before I write a prescription.”