Medical error reporting is the reporting of health care errors (verbal, written, or
other form of communication and the recording of near miss and patient safety events that
involve a reporting system.
Reporting errors is essential in error prevention. There are important reasons to
reporting errors including “hold providers accountable for performance” and “provide
information that leads to improved safety. Reporting harmful errors that were “caught”
before harm was done, errors that did not cause harm, and near-miss errors are as
important as reporting ones that do harm patients.
Due to many errors never reported voluntarily, improvement efforts of Patient
Safety initiatives systems often fail. Errors that occur either do or do not harm patients can
show some problems in the health care system, such as a culture that is not driven towards
safety for patients and their staff members. “To effectively avoid future errors that can
cause patient harm, improvements must be made on the underlying, more-common and
less-harmful systems problems5
%most often associated with near misses.”(Wolf, 2008).
“Health care providers are typically so devastated and embarrassed by their
mistakes that they may attempt to conceal them or defend themselves by shifting the blame
to someone or something else.” (Wolf, 2008). When providers tell the truth, practitioners
and patients share trust. Physicians, nurses and other health care providers have legal and
ethical obligation to report risks.
“Opinions and experiences of hospital leaders about State reporting systems were
solicited from chief executive and chief operating officers of hospitals in six States with a
variety of reporting systems: mandatory, nonconfidential; mandatory, confidential; and
voluntary systems” (Wolf, 2008). Most hospital leaders reported that a mandatory
nonconfidential reporting system run by the State deterred reporting of patient safety
incidents to internal reporting systems. They thought that a mandatory nonconfidential
system encouraged lawsuits.
Leaders have an important role in eradicating the culture of shame and blame.
Some techniques they can use are, leaders should act upon error and hazard reports by
fixing the system vulnerabilities instead of punishing individuals. They should support
system enhancements suggested by staff to reduce risk of harmful errors and leaders
should empower staff to correct safety hazards. Leaders should consistently provide
feedback to staff regarding the actions planned and taken to prevent errors.
%
References
1. Wolf ZR, Hughes RG. Error Reporting and Disclosure. In: Hughes RG, editor.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville
(MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter
35.%Available from: https://www.ncbi.nlm.nih.gov/books/NBK2652/
