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Health Care Industry

Reporting medical errors and adverse events - Research Corner

AORN Journal, April, 2002 by Suzanne C. Beyea

Unlike the aviation industry, the health care industry does not have a structured, systematic approach for reporting errors and adverse events. Learning from errors is a key component of safety initiatives in both military and civilian aviation. Accidents, near misses, and occurrences that actually affect or could affect safe operations of an aircraft are reported to the National Aeronautics and Space Administration's (NASA's) Aviation Safety Reporting System (ASRS) and studied extensively. Knowledge derived from secondary analyses and interview data obtained regarding various incidents results in the dissemination of safety alerts and monthly safety bulletins.

SAFETY IN AVIATION

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Overall safety in the airline industry is protected by three organizations: the Federal Aviation Administration (FAA), the National Transportation Safety Board (NTSB), and the ASRS. The FAA maintains regulatory oversight of the industry and focuses primarily on safety. The NTSB investigates accidents, and, although it has no regulatory or enforcement authority, it can make recommendations to the FAA. The ASRS operates independent of the FAA and has no regulatory or enforcement powers related to civilian aviation.

The ASRS maintains a confidential, voluntary incident reporting system and a database of reported incidents. The purpose is to identify system or latent errors, as well as overt hazards, and to alert the industry about these errors. The ASRS receives more than 30,000 reports annually and issues alerts to the industry on a regular and as needed basis. Most aviation experts agree that these efforts have resulted in an ever-increasing level of civilian airline safety. Experts suggest that if health care could adapt these methods, patient safety could be improved markedly.

HEALTH CARE REPORTING SYSTEMS

The issues associated with a health care reporting system are extremely complex and must be examined critically before implementing a system. Issues include whether systems should be voluntary or mandatory and whether they should be anonymous or confidential. Other issues concern whether systems should be combined or independent and how to finance systems. An overriding concern is the relationship of reporting errors to litigation risks. Regardless of the type of system, it is important to remember that error reports are useful only if there are systematic analyses of the data and follow-up of the aggregated information.

Reporting systems can serve two primary purposes--to hold professionals accountable for their performance and to improve safety. Systems designed to hold professionals accountable are mandatory, whereas systems designed to improve safety are voluntary. Experts agree that both systems are required in health care and that they should be independent. (1)

Mandatory systems address errors that result in serious injury or death or in preventable adverse events. Mandatory systems are operated by state regulatory bodies and ensure that serious errors are reported and investigated and that appropriate action is taken. Voluntary systems generally are confidential and specifically identify the types and patterns of errors that could result in patient injury.

ANONYMITY AND CONFIDENTIALITY

The issues of anonymity and confidentiality concern most health care professionals. Some believe that providing any information about a serious adverse event may place health care professionals and facilities at an increased risk of litigation. This factor and fear of punishment or sanction further contribute to hesitations related to reporting.

Obviously, with anonymous reporting, the individual who makes a report cannot be identified. Data in the report, however, might provide enough information that others could identify the specific situation. This potentially could result in important data not being included in an original report. Another problem with anonymity is that if further information is required about a particular adverse incident, there is no one to contact for further details. These are just some of the issues associated with anonymous reporting systems.

Confidential reporting facilitates the ability to conduct follow-up interviews and obtain more information from those involved in a specific event. The promise of confidentiality is based on the premise that only those who need access to data will have access. Clinicians, however, may not trust such a system fully, fearing confidential information may be disclosed, which could lead to punishment and litigation.

Furthermore, when confidential data are collected and shared with a third party, there are issues related to discovery during a lawsuit. For example, when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted its sentinel event reporting system, there was great controversy about data reported to JCAHO being used in lawsuits against the practitioners involved. This issue has led JCAHO to pursue a federal statute to ensure that data reported to the organization is not considered discoverable.

Health Care Industry

Reporting medical errors and adverse events - Research Corner

AORN Journal, April, 2002 by Suzanne C. Beyea

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