This article first appeared in the St. Louis Beacon: August 7, 2008 - Hospital errors affect all of us: patients or not. One of the first steps in dealing with and reducing the number of errors in hospitals is getting the staff to report them. Often, fear of punishment drives this information underground; but it is imperative that hospitals find ways to get their staff members to not only report mistakes, but to also learn from them.
Delnor-Community Hospital in Geneva, Ill., grappled with this very issue: How to get staff members to report mistakes without the fear of punishment or humiliation. One of the most successful changes it made was simply changing the name of the form the mistakes were reported on. No longer were staff reporting an "error" they began to report "events."
Placed in areas of easy access, these forms were concise; asking for a description of what happened and what could have been done to avoid the problem along with the signature of the staff member involved. These forms were then placed in brightly colored bins in the medication area. Not only has staff begun reporting events more frequently, but changes in how drugs are dispensed on certain hospital floors, have occurred as the result of the continual feedback.
A study done by the University of Iowa found that doctors were more likely to report medical errors to patients than to the medical institution involved.
This same study found that while doctors said that in a hypothetical case they would report both a minor and a major care issue to the institution involved, in reality the majority did not report either of these issues to the institution.
Many doctors claimed they did not know how to file an error claim and they were not sure what kinds of errors they should report. What the doctors seemed to not understand was that by not reporting these errors to the medical institution, they were adversely affecting changes that could improve overall patient care in the future.
Many hospital executives are reluctant to push for formal reporting, fearing more lawsuits and bad press. With dwindling insurance reimbursements and a growing group of individuals who are not covered by health insurance, hospitals fear large lawsuit rewards and the loss of revenue. Yet, the feeling is that the more honest doctors are with patients regarding errors the less likely patients are to sue.
It is up to the health care community to take control of the information reported regarding medical errors.
Patients often do not have the time or the resources to filter through reports and statistics to determine whether the doctor who's on call in the ER is competent or not. From experience, the time to choose a doctor is not when your hand is wrapped in a towel with blood dripping from your elbow. Especially during emergency situations, patients should not have to be concerned about whether the doctor on call is qualified. They should be able to leave that decision up to the medical institution involved.
Patients need to be able to feel secure that the medical institutions they choose for their care can self regulate their staff. Through self reporting and staff development, the hospital has to be proactive rather than wait for a recurring mistake to bring a nurse, pharmacist or doctor to the forefront of their patient care committee. The fear of lawsuits will not go away, as long as under reporting of errors is allowed.
Society often wants to immediately demand a reprimand and punishment for an individual that makes a mistake, but every one of us makes mistakes daily. The difference is that most of our mistakes do not affect someone's health status. By allowing medical personnel to report mistakes or near mistakes without the fear of reprimand and humiliation, the medical community can not only positively change for the better patient care, but can also improve the entire health care system. Medical institutions need to require mandatory reporting of errors by their staff. It is only with this knowledge that health care facilities can continue to provide the best care available and still maintain well qualified staff.
Teresa Small has worked for a large multi-specialty medical clinic in Des Moines, Iowa, for 10 years and tries to keep up on trends in medicine. As a mother and grandmother, she says, "my interest is not only professional, but also personal when it comes to providing and receiving the best health care available."