Approximately 13 years ago, the Institute of Medicine issued a milestone report entitled “To Err is Human” on preventable errors in national hospitals that initiated the patient-safety movement. Unfortunately, according to a study conducted in January of this year, not much has changed: six out of seven hospital-based adverse events, mistakes and accidents go unreported. This could mean that many instances of medical malpractice are being concealed.
The report, the National Incident Study on Adverse Events in Hospitals Among Medicare Beneficiaries, was conducted by the Department of Health and Human Services’ Office of the Inspector General (OIG). The OIG estimated that greater than 130,000 Medicare beneficiaries suffered one or more adverse event in a hospital during a single month. Further, the OIG found that serious adverse events, even ones resulting in death, were not more likely to be reported than minor ones.
Reasons why errors may not be reported include:
- Lack of Recognition: the hospital staff does not view many events as adverse ones or errors at all, but rather as routine
- Fear of Retribution: the staff fears reprisal for errors even if they may not be due to negligence
- Disbelief: denial that adverse events occur and a propensity to bury one’s head in the sand
- Competing Pressures: safety can take a back seat to the increasing burdens of healthcare reform requirements
- Productivity Demands: pressure to maximize the number of patients in order to generate profits increases safety errors
- The Stress of Multi-tasking: the hectic pace of hospital work and the varied simultaneous tasks make doctors more prone to errors
One remedy is to push hospitals towards a “just culture” model of error reporting. A “just culture” approach takes into consideration that when a medical professional makes a mistake that is not due to negligence and could have been done by someone similarly situated, that it is likely the system was a contributing factor. Most hospitals do not make this distinction, and, therefore, honest reporting, which could prevent future errors, is stymied. Indeed, most reports are sent to risk a management department whose goal is to minimize legal exposure.
One example of a “just culture” approach and a hospital that has changed its habits on error reporting is the University of Michigan Health System (UMHS). In 2001, the UMHS set up a full disclosure procedure that combines online incident reporting, a multidisciplinary claims review committee, effective and candid communication with patients and family members, and a quality-improvement initiative directed by reported errors.
Another possible option is a national public reporting system for adverse events similar to what exists for consumer product safety issues. In such a system, anyone, from a patient to a hospital staff member, could report events online as well as receive follow-up and assistance related to their report.
The one thing that is certain is that the healthcare industry should not continue to ignore the issue or call for more research; action is needed and needed now.