TITLE

How a System for Reporting Medical Errors Can and Cannot Improve Patient Safety

AUTHOR(S)
Clarke, John R.
PUB. DATE
November 2006
SOURCE
American Surgeon;Nov2006, Vol. 72 Issue 11, p1088
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
The Institute of Medicine has recommended systems for reporting medical errors. This article discusses the necessary components of patient safety databases, steps for implementing patient safety reporting systems, what systems can do, what they cannot do, and motivations for physician participation. An ideal system captures adverse events, when care harms patients, and near misses, when errors occur without any harm. Near misses signal system weaknesses and, because harm did not occur, may provide insight into solutions. With an integrated system, medical errors can be linked to patient and team characteristics. Confidentiality and ease of use are important incentives in reporting. Confidentiality is preferred to anonymity to allow follow-up. Analysis and feedback are critical. Reporting systems need to be linked to organizational leaders who can act on the conclusions of reports. The use of statistics is limited by the absence of reliable numerators and denominators. Solutions should focus on changing the cultural environment. Patient safety reporting systems can help bring to light, monitor, and correct systems of care that produces medical errors. They are useful components of the patient safety and quality improvement initiatives of healthcare systems and they warrant involvement by physicians.
ACCESSION #
23041976

 

Related Articles

  • National patient safety database would track medical errors.  // Formulary;Sep2004, Vol. 39 Issue 9, p461 

    Reports that the United States Senate passed the Patient Safety and Quality Improvement Act, which would establish a national patient safety database and create healthcare information technology standards to track medical errors.

  • Patient Safety in the Ambulatory Setting. Plews-Ogan, Margaret L.; Nadkarni, Mohan M.; Forren, Sue; Leon, Darlene; White, Donna; Marineau, Don; Schorling, John B.; Schectman, Joel M. // JGIM: Journal of General Internal Medicine;Jul2004, Vol. 19 Issue 7, p719 

    Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or...

  • An empirical study for medication delivery improvement based on healthcare professionals’ perceptions of medication delivery system. Mazur, Lukasz; Shi-Jie Chen // Health Care Management Science;Mar2009, Vol. 12 Issue 1, p56 

    Medication errors are major safety concerns in all hospital settings. The insufficient knowledge about managerial and process improvement strategies required to reduce medication errors can be considered as one of the most important factors holding back hospitals from achieving the desired goals...

  • Being open with patients about medical error: challenges in practice. Ottewill, M.; Vaughan, C. // Clinical Ethics;2010, Vol. 5 Issue 3, p159 

    There is a significant body of evidence showing that patients want to know when they are harmed as a result of their medical care. In 2005 the National Patient Safety Agency issued guidance on the process to be followed when communicating errors to patients and their carers. However, there is...

  • When doctors don't know best.  // Consumer Reports on Health;Apr2002, Vol. 14 Issue 4, p1 

    Reports on the failure of doctors to give patients the proper treatment. How doctors may be unable to keep up with the most recent discoveries in medicine; Failure to use screening tests for diseases, such as colon cancer and depression; Lack of prescriptions for cholesterol-lowering drugs for...

  • A Business Case for Patient Safety. Oetgen, William J.; Oetgen, Phyllis M. // Physician Executive;Sep/Oct2003, Vol. 29 Issue 5, p39 

    Discusses the aspects of the business case of patient safety. Business activities and concern of patient safety; Role of physicians in guarding patient safety and reducing medical errors; Citations of the elements helping physician executives understand the business case for patient safety.

  • "Second Victim" Casualties and How Physician Leaders Can Help. Macleod, Les // Physician Executive;Jan/Feb2014, Vol. 40 Issue 1, p8 

    The article discusses several ways by which health care organizations can help physician second victims. It notes that medical errors has serious consequences for 3 different kinds of victims namely patients, caregivers and health care organizations where they occur. It indicates that medical...

  • Wisdom through Failure: Exemplary Physicians Discuss Their Regrets. Meldrum, Helen // Physician Executive;Mar/Apr2012, Vol. 38 Issue 2, p26 

    The article highlights several medical mistakes and miscommunications. It states that some doctors feel partially responsible for their patients' decision, often seeing them as a failure to effectively influence. Meanwhile, some doctors express some regret regarding their inability to mobilize...

  • A missed diagnosis. Persad, Atma // CMAJ: Canadian Medical Association Journal;12/7/2004, Vol. 171 Issue 12, p1439 

    Presents an article on committing an error in patient assessment. Mistake committed regarding the real medical condition of a patient; Reaction of the patient towards the error; Reaction of a physician towards the incident.

Share

Read the Article

Courtesy of THE LIBRARY OF VIRGINIA

Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics