Dr. Nussenbaum said he tries to make sure that his residents do better. “If important adverse events are not being reported, then a discussion about these events does not happen and we can’t learn how to improve,” he said.
Explore this issue:April 2012
All his residents have a small card that fits in a shirt pocket. “It lists a set of criteria for reporting that all otolaryngology attendants agreed upon. If any of these events happen, they should be reported,” he said. The indicators were derived from recommendations by the Institute for Healthcare Improvement, the Agency for Healthcare Research and Quality and the American College of Surgeons, along with suggestions by attendings in his department.
The system usually yields about 15 to 20 adverse events reports per month. “At our mortality and morbidity conference, we discuss all mortalities, all reviewable events and all near misses,” Dr. Nussenbaum said. “The residents are particularly encouraged to discuss the near misses; those are the ones we feel that we learn a lot from. We analyze cases in a Just Culture manner, balancing personal accountability with system factors, and come up with a plan of what to do to try to proactively prevent these events from happening again.”
Over the past two years, this approach has led to numerous changes in patient care, including elimination of the use of unguarded bipolar cautery devices, placement of pre-mixed calcium gluconate on the floor for stat orders and implementation of airway tattoos on hospitalized laryngectomy patients.
But not all otolaryngologists are convinced that simply increasing the number of adverse events and errors reported is a goal to be pursued.
“No matter how precisely you try to define it, there are fuzzy boundaries,” said David Roberson, MD, associate in otolaryngology and director of implementation for the Program for Patient Safety and Quality at Children’s Hospital in Boston. “It would be easier to crack down on adverse event reporting if there were 100 percent agreement on what constituted a reportable adverse event.”
Children’s Hospital implemented an adverse event reporting system about five or six years ago, Dr. Roberson said. For the first three years, the number of events reported rose steadily, and then it plateaued. Now, the 400-bed hospital has about 15,000 adverse event reports per year.
“Several hundred of them are IV infiltrates,” Dr. Roberson said. “It’s nice to be able to count those and say we’d like that number to be smaller than it was last year, but is the world a better place because for every IV infiltrate, we have the nurse fill out a three-page form? With 15,000 reports a year, we can’t thoughtfully analyze them all. We do a serious analysis on the level three, four and five errors and those judged preventable. Let’s say the one in seven figure from the OIG report is correct and we ought to have 100,000 errors reported every year. How would we handle that number?”
—Rosemary Gibson, MSc
The science of error reporting in medicine, and what to do with the information gathered, is still evolving, Dr. Roberson said. “It’s relatively new for most hospitals to have all this information and to know what to do with it. Most take it as a public health ideal that every adverse event be reported, but I don’t think there’s any proof that it’s better to have all events reported than half.”