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Patient Safety and Quality

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Doctors are willing to report and learn from medical mistakes, but find error-reporting systems inadequate

U.S. doctors are willing to report medical errors and learn from their mistakes. However, most doctors think that current systems to report and share information about errors are inadequate. They rely instead on informal discussions with their colleagues. As a result, important information about medical errors and how to prevent them is often not shared with the hospital or health care organization, concludes a study supported by the Agency for Healthcare Research and Quality (HS11890 and HS14020).

To assess physicians' attitudes about communicating medical errors with their colleagues and health care organizations, the study authors surveyed a diverse group of 1,082 physicians in two States in 2003 and 2004. Most physicians reported that they had been involved in an error—56 percent reported a prior involvement with a serious error, 74 percent with a minor error, and 66 percent with a near miss. More than half (54 percent) agreed with the statement that "medical errors are usually caused by failures of care delivery systems, not failures of individuals."

Most physicians agreed that they should report errors to their hospital or health care organization and needed to know about errors made in those organizations in order to improve patient safety. Yet only 30 percent agreed that current systems to report patient safety events were adequate. Physicians were more likely to discuss errors and near misses with their colleagues than to report them to a risk management or patient safety official.

Surveyed doctors said they would be more willing to formally report error information if information would be kept confidential and nondiscoverable (88 percent); there was evidence that such information would be used for system improvements (85 percent) and not for punitive action (84 percent); the error-reporting process would take less than 2 minutes (66 percent); and the review activities would be confined to their department (53 percent).

More details are in "Lost opportunities: How physicians communicate about medical errors," by Jane Garbutt, MB.Chb., F.R.C.P., Amy D. Waterman, Ph.D., Julie M. Kapp, Ph.D., M.P.H., and others, in the January/February 2008 Health Affairs 27(1), pp. 246-255.

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