Dr. Shah uses the phrase “zones of risk” to describe the areas of vulnerability for otolaryngologists. “We use sophisticated equipment, we do myriad surgeries, we work in the airway with oxygen and electrocautery, which entails a potential risk of fire, and we operate on many sites of surgery in a closed cavity,” he said. “We’re uniquely vulnerable.” (See also, “Adverse Events in the Medical Office Setting.”)
Explore This IssueApril 2012
One hospital that is far ahead of the curve in error reporting is the University of Michigan Health System. In 2001, just two years after the release of To Err Is Human, the health system adopted a process of full disclosure of medical errors that involves multiple components, including an online incident reporting system, a multidisciplinary claims review committee, open and honest communication with patients and families and quality improvement initiatives guided by reported errors.
“They’ll get 7,000 or 8,000 reports a year from staff,” Gibson said. “That’s what you want. Most of them are minor or near misses, and you want to know about those so you can learn from them and prevent the larger errors. But you have to create a space where it’s safe for people to report.”
She said hospitals must adhere to the “Just Culture” principle in error reporting, a philosophy that recognizes that even competent professionals make mistakes. Quality improvement leader and Harvard School of Public Health Professor Lucian Leape, MD, has said that the biggest impediment to error reporting and prevention in medicine is “that we punish people for making mistakes.” A Just Culture model strikes a balance between personal accountability and the complex systems health care professionals work in and, when errors are made, establishes mechanisms to appropriately attribute responsibility to both individuals and systems.
“If I made a mistake and anybody else in my position could have made that same mistake, the chances are the system contributed to my making that mistake, and Just Culture would suggest I shouldn’t bear all the blame for it,” Gibson said. “That’s different from a case in which I did something that was truly negligent. Hospitals often do not make this distinction and lack a Just Culture.”
But traditional reporting systems in health care often do not support a Just Culture model or a truly patient safety-focused approach, said Brian Nussenbaum, MD, Christy J. and Richard S. Hawes III Associate Professor of Otolaryngology and Head and Neck Surgery at Washington University School of Medicine in St. Louis. “Paper or online reports are sent to hospital risk management departments, whose concerns are primarily to limit the potential legal risk. There is little emphasis on systems improvement or prevention, dissemination of incidents to others in the organization is unusual and the impact on clinical care is often not felt by providers.” (See “Hospital-Based Safety Programs: Making Them Work.”)
Whose Responsibility Is It?
Who should be reporting errors? Ideally, the responsibility lies with everyone involved in patient care, Dr. Nussenbaum said. In practice, physicians are more likely to report events that caused permanent harm or the death or near death of a patient, but overall they report only 1 percent of adverse events (Jt Comm J Qual Patient Saf. 2008;34(9):537-545). Nurses, who are more likely to report events that cause no harm or harm that’s only temporary, report about 45 percent of events. In the same study, residents reported only a little more than half of adverse events to attending physicians.