As we continually highlight on this blog, nearly 100,000 Americans die
yearly because of
medical errors. While many health care facilities have taken steps to address medical
errors and improve patient safety, many medical mistakes still go unreported.
Several studies have determined that fear of retaliation and embarrassment
often keep health care providers from reporting mistakes. Most recently,
a study found that reporting medical errors through a system that emphasizes
a lack of punishment and maintains anonymity leads to more reports than
traditional reporting tools.
As part of the study, Dr. Daniel Neuspiel, the director of ambulatory pediatrics
at Levine Children’s Hospital in Charlotte, North Carolina, and
his colleagues trained a “pediatric safety champion team”
to implement a new reporting system in a large clinic in Charlotte, North Carolina.
Members of the team were recruited from all facets of the practice, from
the physicians to the front desk staff. They educated employees about
the new medical error reporting initiative, and emphasized that all reports
would remain anonymous and no one would be punished for making a mistake.
The safety team met monthly to review the errors that the staff reported,
and to develop ways to prevent the errors from reoccurring.
In the last year of the old system, there were just five error reports.
After two and a half years under the new system, however, the safety team
had collected and reviewed 216 reports, most of which were submitted by
doctors and nurses.
There were 68 cases of entering incorrect information on a patient’s
record, 27 instances of laboratory tests being delayed or neglected, 24
medication errors, and 21 mistakes involving vaccines.
The team addressed three-quarters of the errors with changes in the practice.
For instance, to prevent nurses from giving kids the wrong vaccine, the
office implemented a policy to remove all distractions and other tasks
from nurses while they are preparing the shots.
The reforms Neuspiel and his team brought to the practice are now a permanent
part of the office. He expects that this type of system would be easy
to install in other outpatient practices.
“These types of errors are going on everywhere, so I’m hoping
more practices will consider making changes,” he said.