Article

Error Reporting and Disclosure Systems: Views From Hospital Leaders

Institute for Health Policy, Massachusetts General Hospital, Boston 02114, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 04/2005; 293(11):1359-66. DOI: 10.1001/jama.293.11.1359
Source: PubMed

ABSTRACT The Institute of Medicine has recommended establishing mandatory error reporting systems for hospitals and other health settings.
To examine the opinions and experiences of hospital leaders with state reporting systems.
Survey of chief executive and chief operating officers (CEOs/COOs) from randomly selected hospitals in 2 states with mandatory reporting and public disclosure, 2 states with mandatory reporting without public disclosure, and 2 states without mandatory systems in 2002-2003.
Perceptions of the effects of mandatory systems on error reporting, likelihood of lawsuits, and overall patient safety; attitudes regarding release of incident reports to the public; and likelihood of reporting incidents to the state or to the affected patient based on hypothetical clinical vignettes that varied the type and severity of patient injury.
Responses were received from 203 of 320 hospitals (response rate = 63%). Most CEOs/COOs thought that a mandatory, nonconfidential system would discourage reporting of patient safety incidents to their hospital's own internal reporting system (69%) and encourage lawsuits (79%) while having no effect or a negative effect on patient safety (73%). More than 80% felt that the names of both the hospital and the involved professionals should be kept confidential, although respondents from states with mandatory public disclosure systems were more willing than respondents from the other states to release the hospital name (22% vs 4%-6%, P = .005). Based on the vignettes, more than 90% of hospital leaders said their hospital would report incidents involving serious injury to the state, but far fewer would report moderate or minor injuries, even when the incident was of sufficient consequence that they would tell the affected patient or family.
Most hospital leaders expressed substantial concerns about the impact of mandatory, nonconfidential reporting systems on hospital internal reporting, lawsuits, and overall patient safety. While hospital leaders generally favor disclosure of patient safety incidents to involved patients, fewer would disclose incidents involving moderate or minor injury to state reporting systems.

0 Followers
 · 
94 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Although quality information has been collected by governmental and private agencies for over three decades, public access to this information has typically been cumbersome. Recently, an initiative was launched in California in which hospitals can volunteer to provide a series of quality indicators on a user-friendly website. We investigate the factors associated with choosing to participate in this public disclosure initiative and find that hospitals participating in CHART exhibited higher quality and better financial performance than those that do not participate.
  • Source
  • [Show abstract] [Hide abstract]
    ABSTRACT: Healthcare professionals have an ethical and professional responsibility to report medical errors. Doctors in particular are duty bound to consider the best interests of their patients and 'do no harm'. Medical errors are rarely due to individual human error but are often systems based and in many cases are avoidable. Reporting and learning from medical errors improves the safety of patients. It has been over ten years since the reports To Err Is Human and An Organisation with a Memory highlighted the scale of preventable medical errors. These statistics, stimulated worldwide health organisations to prioritise patient safety. Both reports recommended the implementation of a voluntary near-miss reporting system and mandatory reporting of serious adverse incidents that had caused physical or psychological harm or death. Currently in Scotland reporting of all errors is voluntary and there is no sharing of information between Health Boards. Studies have demonstrated failings of the voluntary system and preventable medical errors are still occurring in Scotland. The UK Government in England as of April 2010 has changed the voluntary system of reporting serious adverse events to a mandatory obligation. Failure to report may result in a fine of £4000 to the Trust. Patient groups wish the system in Scotland to become mandatory with public disclosure. This would ensure openness, honesty and autonomy for patients. This article reviews the controversial issue of mandatory reporting and whether or not this would improve the safety of patients. In conclusion, Scotland would benefit from mandatory reporting of serious adverse events and voluntary near-miss reporting.
    Journal of Forensic and Legal Medicine 10/2012; 19(7):437-41. DOI:10.1016/j.jflm.2012.04.007 · 0.99 Impact Factor