Reporting medical errors and adverse events - Research Corner

AORN Journal,  April, 2002  by Suzanne C. Beyea

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DEVELOPING SYSTEMS

Experts agree that the health care industry requires both a mandatory and voluntary reporting system. It remains unclear how to best finance these systems or who should be responsible for their management. For example, individuals involved in the civil airline industry resisted the ASRS until it was transferred to NASA. They perceived a group independent of the FAA as more trustworthy, and this significantly increased compliance with the reporting process.

The complexity of developing national databases of mandatory and voluntary systems cannot be addressed easily. It is clear, however, that the health care industry needs databases with reliable and valid data about medical errors to address preventable problems. Unless we have information about the nature and extent of adverse events and near-misses, trends and patterns cannot be identified. Without this data and understanding, it is difficult to provide alerts and determine safe practices.

CONCLUSION

One safety expert says that "fear and lack of belief that it results in improvement" are the two primary reasons that errors are not reported. (2) Evaluate the current reporting system in your facility and state. Find out more about how it works, whether you can access information about the system, and whether it is voluntary or mandatory, confidential or anonymous. Explore the pros and cons of the way data are handled and reported. Visit the JCAHO web site at http://www.jcaho.org and examine reports of sentinel events and related alerts. Consider how that information has the potential for improving clinical performance, specifically nursing practice, at your facility. Learn more about reporting systems by reading or attending education sessions on the topic. There are many initiatives that evaluate the efficacy and effectiveness of various types of health care reporting systems, and the more you know, the more prepared you will be for the implementation of a reporting system.

This column provides a beginning discussion of some of the issues related to this topic. It is not intended to be a complete discussion of the issues related to reporting systems. For further information on this topic, please see the resources at the end of the article.

SUZANNE C. BEYEA
RN, PHD
AORN DIRECTOR OF RESEARCH

NOTES

(1.) Institute of Medicine, To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000)

(2.) L L Leape, "Why should we report adverse incidents?" Journal of Evaluation in Clinical Practice 5 (February 1999) 1-4.

RESOURCES

Institute of Medicine. To Err is Human: Building a Safer Health System (Washington, DC: National Academy Press, 2000).

Karson, A S, Bates, D W. "Screening for adverse events," Journal of Evaluation in Clinical Practice 5 (February 1999) 23-32.

Leape, L L. "Why should we report adverse incidents?" Journal of Evaluation in Clinical Practice 5 (February 1999) 1-4.

Stanhope, N, et al. "An evaluation of adverse incident reporting," Journal of Evaluation in Clinical Practice 5 (February 1999) 5-12.