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A 3-year, multi-method research project funded by the Agency for Healthcare Research and Quality (HS11930) examined the organizational processes that influence the recognition of medical errors and assignment of responsibility for resolution of patient safety problems. The research was carried out in 29 small rural hospitals in nine Western States and involved seven substudies that used surveys, questionnaires, interviews, and case studies to gather data from nurses, physicians, administrators, pharmacists, and other health care workers.
The researchers found that when responding to case studies and surveys, participants agreed that medication-related errors were the most common kind of error. They also responded positively about their hospitals' commitment to patient safety. Most believed that the hospital culture supported the idea that "anyone can make mistakes" (64 percent), and that the error reporting system was open to all employees (86 percent), confidential (69 percent), and impartial (56 percent). On the other hand, providers' understanding of patient safety was heavily conditioned by preconceived notions of what constitutes an error and professional roles, according to lead investigator Ann Freeman Cook, Ph.D., of the University of Montana in Missoula. As a result, the agreement as to errors related to diagnosis and treatment was less consistent.
For example, nurses noted that if their relationships with physicians were problematic or if they lacked the support of their hospital's administration, they were hesitant to question clinical practices. Also, analyses of case studies showed that health care providers didn't agree on what constitutes error or what kinds of events should be reported. In one substudy, a hospital-wide survey, even when there was overwhelming agreement (97 percent) that an error had occurred, only 64 percent of providers said they would disclose the error to the affected patient. Physicians, administrators, and nurses tended to perceive patient safety as primarily a nursing responsibility. Only 22 percent of respondents to that survey said that physicians, nurses, pharmacists, and administrators should share responsibility equally for patient safety.
In an earlier study conducted by the investigators, only 8 percent of physicians identified nurses as members of the decisionmaking team. This could be a factor in nurses' reluctance to question physicians' clinical judgment or to take corrective action in response to error, according to Dr. Cook. Dr. Cook and her colleagues propose that a systems approach to patient safety be adopted, one in which responsibility for safety is shared by all members of the health care team.
Details are in "An error by any other name," by Dr. Cook, Helena Hoas, Ph.D., Katarina Guttmannova, M.A., and Jane Clare Joyner, J.D., R.N., in the June 2004 American Journal of Nursing 104(6), pp. 32-43.
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