Error-reporting Systems Inadequate, Physicians Say

The nation's physicians are willing to report medical errors, and they want to learn how to prevent them. They just don't have much faith in current error-reporting systems and, as a result, tend to share error information informally with their colleagues but not with their hospital, a new study concludes.

"Lost Opportunities: How Physicians Communicate About Medical Errors" (abstract is free; nonsubscribers pay $12.95 for the full article) appears in the January/February Health Affairs. The study was funded by the Agency for Healthcare Research and Quality.

Study authors polled more than 1,000 physicians and surgeons in academic and private practice in rural and urban areas of Washington and Missouri. Family physicians were included in the study sample. Fifty-six percent of study respondents reported they had been involved with a serious error, 74 percent with a minor error and 66 percent with a "near miss." Slightly more than half (54 percent) agreed that medical errors usually are caused by systems failures, not failures of individuals.

Most agreed that they should report errors to their hospitals or health care organizations to improve patient safety, and 83 percent said they had used at least one formal reporting mechanism. But physicians were more likely to discuss error information informally with their colleagues than to report the information to a formal system. This creates "lost opportunities to implement effective system-level solutions to prevent future errors," the study authors write.

Only 30 percent of respondents agreed that current systems for reporting errors were adequate, and only 19 percent agreed that current systems to disseminate error information to physicians were adequate. Only about one in five respondents said they thought they had access to a reporting system that was designed to improve patient safety.

When asked what would increase their willingness to report errors to a formal system, respondents said the system should be nonpunitive and should keep reported information confidential and nondiscoverable. They wanted evidence that the information would be used for system improvements, and they wanted the reporting process to be quick and local to their unit or department.

The authors note that hospitals and health care organizations increasingly are required to report serious adverse events and errors to state regulators and the Joint Commission on Accreditation of Healthcare Organizations. In addition, HHS just published proposed regulations in the Feb. 12 Federal Register to implement the Patient Safety and Quality Improvement Act of 2005. (At the Federal Register site, access the proposed regulations by typing "42 CFR Part 3" in the "2008 (Volume 73) Only" search field.) The act authorizes the creation of patient safety organizations, or PSOs, to collect, aggregate and analyze confidential information voluntarily reported by health care providers. The PSOs are intended to provide feedback about successful ways to reduce risk and improve patient safety.

Hospitals should develop communication strategies to make physicians aware that information they share with error reporting systems generally is protected from legal discovery under quality assurance statutes, the study authors write. "Furthermore, the guarantee of confidentiality for reporting to the new patient safety organizations must be clearly articulated and widely disseminated to all users."

Further research should look into transforming the physician work culture in ways that emphasize error reporting to support quality improvement, the authors say. They also call for research into ways formal reporting systems can capture error information shared informally among physician colleagues.

In addition, the authors encourage research to evaluate physicians' preferences for specialty-specific or institutionally based error-reporting systems. Citing a 2004 study as an example, they note that when neonatal intensivists from many institutions agreed to use a Web-based reporting system, "rare errors were identified, and dissemination of findings through an e-mail discussion list and annual meetings prompted many patient safety improvement projects at participating institutions."