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Blame Free Medical Error Reporting Lead Safer Hospitals?

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.