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: 35.29). 04/2005; 293(11):1359-66. DOI: 10.1001/jama.293.11.1359
Source: PubMed


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.

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    • "Prior studies that have explored the impact of quality reporting initiatives , have provided evidence that public reporting of quality helps hospitals improve their services [29] [55] and that patients desire information about error disclosure [30] even though they face barriers to finding or interpreting the information [26] [35] [80]. More troubling is the suggestion that mandatory quality disclosure may discourage reporting quality incidents [82] or cause providers to avoid high-risk patients [21]. Indeed, the limitations of existing mandatory reporting systems and the CMS program have led to the subsequent formation of coalitions in a number of states for creating voluntary hospital reporting systems. "
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    • "It is clearly easier to sublimate than to face the problem head on. This phenomenon may occur at the highest level of hospital medicine; in a survey of hospital leaders' views on error reporting and disclosure, Chief Medical Officers were less likely than Chief Executive Officers or Chief Operating Officers to be prepared to disclose moderate or minor injuries to the patient [35]. Wu [36] has coined the term ''the second victim'' to capture the vulnerability of the physician or other health care practitioner at the sharp end of the error. "
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    • "For this reason, hospital managers demonstrate concerns about the impact of a mandatory and non-confidential reporting system, as it not only discourages reporting activities but encourages lawsuits with negative consequences for patient safety (Weissman et al. 2005). This aspect is closely related to and inseparable from institutional aspects in broader terms, as discussed below (e.g. the tort system, expert risk assessment, and regulatory framework) (Vincent 2003; Berlin 2006; Abraham and Davis 2005). "

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