Healthcare Industry Error Reporting Systems
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Reporting Medical Errors To Improve Patient Safety
editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for medical error reporting patient safety and the physician Healthcare Research and Quality (US); 2008 Apr. Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Show detailsHughes RG, editor.Rockville (MD): Agency for Healthcare Research and
What Is A Systems Approach To Addressing Error?
Quality (US); 2008 Apr.ContentsSearch term < PrevNext > Chapter 35Error Reporting and DisclosureZane Robinson Wolf; Ronda G. Hughes.Author InformationZane Robinson Wolf;1 Ronda G. Hughes.21 Zane Robinson Wolf, Ph.D., R.N., F.A.A.N., dean and professor, La Salle University School of Nursing and Health Sciences. E-mail: ude.ellasal@flow2 Ronda G. Hughes, Ph.D., M.H.S., medical error reporting policy R.N., senior health scientist administrator, Agency for Healthcare Research and Quality. E-mail: vog.shh.qrha@sehguH.adnoRBackgroundThis chapter examines reporting of health care errors (e.g., verbal, written, or other form of communication and/or recording of near miss and patient safety events that generally involves some form of reporting system) and these events’ disclosure (e.g., communication of errors to patients and their families), including the ethical aspects of error-reporting mechanisms. The potential benefits of intrainstitutional and Web-based databases might assist nurses and other providers to prevent similar hazards and improve patient safety. Clinicians’ fears of lawsuits and their self-perceptions of incompetence could be dispelled by organizational cultures emphasizing safety rather than blame. This chapter focuses on the assertion that reporting errors that result in patient harm as well as seemingly trivial errors and near misses has the potential to strengthen processes of care and improve the quality of care
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Compliance Reporting Errors In Patient Care
Page 86 Share Cite Suggested Citation: "5 Error Reporting Systems." Institute of Medicine.
Mandatory Reporting Of Medical Errors
To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000. doi:10.17226/9728. × Save Cancel patient safety reporting system mhs Page 865— Error Reporting SystemsAlthough the previous chapter talked about creating and disseminating new knowledge to prevent errors from ever happening, this chapter looks at what happens after an error occurs and http://www.ncbi.nlm.nih.gov/books/NBK2652/ how to learn from errors and prevent their recurrence. One way to learn from errors is to establish a reporting system. Reporting systems have the potential to serve two important functions. They can hold providers accountable for performance or, alternatively, they can provide information that leads to improved safety. Conceptually, these purposes are not incompatible, but in reality, they can prove difficult to satisfy simultaneously.Reporting https://www.nap.edu/read/9728/chapter/7 systems whose primary purpose is to hold providers accountable are "mandatory reporting systems." Reporting focuses on errors associated with serious injuries or death. Most mandatory reporting systems are operated by state regulatory programs that have the authority to investigate specific cases and issue penalties or fines for wrong-doing. These systems serve three purposes. First, they provide the public with a minimum level of protection by assuring that the most serious errors are reported and investigated and appropriate follow-up action is taken. Second, they provide an incentive to health care organizations to improve patient safety in order to avoid the potential penalties and public exposure. Third, they require all health care organizations to make some level of investment in patient safety, thus creating a more level playing field. While safety experts recognize that Page 87 Share Cite Suggested Citation: "5 Error Reporting Systems." Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press, 2000. doi:10.17226/9728. × Save Cancel Page 87errors resulting in serious harm are the "tip of the iceberg," they represent the small subset of errors that signal major system breakdowns with grave consequences for patients.Reporting
of Clinical Oncology. Medical Errors: Focusing More on What and Why, Less on Who Remember, there is nothing you can do to change [the past], but you can use its lessons to improve your future. —Rabbi Abraham J. http://jop.ascopubs.org/content/3/2/66.full Twerski, MD Disclosure of medical errors and improvement in patient safety are inexorably linked, and provide one of the strongest reasons to report and disclose errors, including near misses in which no harm comes to the patient. As Rosner et al1 notes, “The paradox of modern quality improvement is that only by admitting and forgiving error can its rate be reduced.” Error reports can be valuable learning tools as well—both for those immediately error reporting involved and for the health care community at large. Nevertheless, US health care has not had a good record when it comes to reporting medical errors, even significant ones. For example, 20 states have mandatory reporting systems, but only six have received more than 100 reports in 1999. Yet the Institute of Medicine (IOM; Washington, DC) estimates that more than 1 million preventable adverse events occur each year in the United States, with up error reporting system to 98,000 being fatal, a figure equivalent to one major airliner crash daily.2,3 Next Section Overcoming Barriers Barriers to error reporting are found at many levels in the health care system. Moskop et al4 assert that US health systems are not generally designed to encourage error recognition, reporting, and remediation. Teaching hospitals have focused on the sequelae of errors rather than teaching ways to prevent them or the value of disclosing them. Physicians' training and attitudes place additional barriers to reporting errors. As the gatekeeper for a patient's care, the physician who commits an error, especially one that harms the patient, may feel deep shame, guilt, and a sense of failure. He or she may believe that disclosing the error to the patient will do irreparable damage to the physician-patient relationship and to the patient's trust in the health care system in general. Furthermore, physicians have historically received little or no training in how to communicate with patients and others about errors. Reporting systems have been relatively cumbersome. The process of completing detailed forms, submitting them up the chain of command, and attending meetings and interviews has deterred many health care professionals from reporting all but the most egregious errors. Both institutions and individual practitioners view the threat of malpractice liability as a significant barrier to error reporting. The disclos