Underreporting Medical Errors

In the article, Introducing incident reporting in primary care: a translation from safety science into medical practice, the authors speak of how most reported incidents were ones that caused little or no injury to the patient. They found those providing care were able to deal with these incidents more

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

Also enforced by OCR, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established a voluntary reporting system where data is analyzed and used to enhance the safety and quality of healthcare delivery. PSQIA provides confidentiality protections to healthcare providers who were previously concerned about the use of patient safety event reports in criminal, civil, and administrative proceedings. By limiting the use of event reports the fear report medical errors has decreased among many healthcare providers (Medical Errors and Patient Safety, 2008).

The third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

Medical errors have adverse effect on health care organization structure because it put a question mark on health profession’s reputation. The medical error definitely can cause harm to the patient or even the death. Medical errors can happen anywhere in healthcare system: in hospitals, clinics, surgery rooms. Medical mistakes can arise from doctors, nurses, surgeons, hospital administration, and many others. Medical errors affect the health care organizational structure, culture, and social in many ways. Medication errors have severe direct and indirect effects on health care organizational structure, and culture is usually the outcome of breakdowns in a system of care. Many reasons can involve in medical errors such as, miscommunication

errors is fundamental to prevent errors and improve patient safety (Wolf & Hughes, 2008). There

“More than half of the healthcare workers surveyed have witnessed a small percentage of their coworkers break rules, make mistakes, fail to support, demonstrate incompetence, show poor teamwork, disrespect them, and micromanage. Many have seen colleagues cutting corners, making mistakes, and demonstrating incompetence.”(AACN). The HHS or the Department of Health and Human Services, released a document in 2012 under the guidance of Inspector General Daniel R. Levinson, which states that the reporting systems in hospitals to report mistakes are are not used, and were not adequate mainly due to workers confusion on when to use it and how to use it “Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm. Of the events experienced by Medicare beneficiaries discharged in October 2008, hospital incident reporting systems captured only an estimated 14 percent.” (OIG). The Attorney General’s office gave suggestions to hospitals including but not limited to “create a list of potentially reportable events and provide technical assistance to hospitals in using the list.”(OIG) this would be to simplify the process to give no other option than to report these errors to help their patients receive

The Health Care Industry is complex and is responsible for the health of the country (The Hospital & Healthsystem Association of Pennsylvania; Outcome Engineering, 2010), and ultimately of the world. Unfortunately, according to the Institute of Medicine's comprehensive report, "To Err Is Human," avoidable medical errors annually kill 44,000 - 98,000 hospital patients (Reiling, Knutzen, & Stoecklein, 2003). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: "wrong site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape or homicide; perinatal death or loss of function; patient death or injury in restraints" (HealthLeaders Media, 2010). Clearly, many of these

The article stresses that in order to maintain a culture of safety, nurses and caregivers must be encouraged to report medical errors, near misses or adverse events without fear of retaliation.

Reporting errors are essential to error prevention. There is two type of Reporting systems, mandatory reporting systems and voluntary reporting systems. The mandatory reporting systems it is for errors associated with serious injuries or death. In mandatory reporting systems, there are penalties or fines for wrong-doing and this is detected by state regulatory programs that have the authority to investigate specific cases. The aims of these systems to assuring for the patients that there is a report and investigate and appropriate follow-up for serious errors and action is taken. In addition, they encourage healthcare organizations to improve patient safety to avoid the potential penalties and public exposure. Moreover, they require all healthcare

When it comes to health care and mistakes; consequences could be as minor as a rash to as major as loss of life. Making prevention a true part of care or cure, is to the most benefit to hospitals. Identification of the factors which lead to human error and implement procedures in order reduce serious mistakes is the top priority within governmental health care settings. In the health care there are several defenses in place that must fail in order for a detrimental or life threatening events to happen. Failure of these mechanism that impedes in harmful outcomes is known as a near miss. There are several factors that result in these mistakes. Human error is the greatest risk factor.

The concern with not educating trainees before graduation is that incident and near misses tend to remain underreported because of the perpetuating negative culture surrounding error reporting. This in turn hinders learning from the event and stifles growth toward voluntary sharing of broken processes and system failures (Barnsteiner, 2011). The current focus on Quality Improvement is to provide high reliable care with little to zero risks by including the “combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (IHI, 2015).