A Medical Device Daily

The “rubber” concerning clinical mistakes meets the “road” in the minds of physicians — but perhaps even more in methods for reporting errors, according to a new study by the Agency for Healthcare Research and Quality (AHRQ; Washington). And the study suggests that there is a clear need for formalizing the systems for reporting these mistakes.

Carolyn Clancy, MD, head of AHRQ, said that a new survey shows that physicians “say they want to learn from errors that take place in their institution to improve patient safety. We need to build on that willingness with error-reporting programs that encourage their participation.”

She says the study indicates that physicians are willing to report and learn from medical errors, rather than, according to the general perception, that they resist doing this. Because most doctors think that current systems to report and share information about errors are inadequate, they rely instead on informal discussions with their colleagues.

“Consequently,” the organization said in a statement, “important information about medical errors and how to prevent them often is not shared with the hospital or the healthcare organization.”

“These findings shed light on an important question — how to create error-reporting programs that will encourage clinician participation,” said Clancy.

To assess physicians’ attitudes about communicating errors with their colleagues and healthcare organizations, study authors used a 68-question survey to poll a geographically diverse group of more than 1,000 physicians and surgeons practicing in rural and urban areas in the states of Missouri and Washington, between July 2003 and March 2004.

Most physicians reported that they had been involved in an error – 56% reported a prior involvement with a “serious error,” 74% with a “minor error and 66% with a near miss. More than half (54%) agreed with the statement that “medical errors are usually caused by failures of care delivery systems, not failures of individuals.”

Other findings:

• The majority of physicians agreed that they should report errors to their hospital or healthcare organization to improve patient safety.

• Almost all (95%) physicians agreed that they needed to know about errors in their organization to improve patient safety, and 89% agreed that they should discuss errors with their colleagues.

• 83% said they had used at least one formal reporting mechanism, most commonly reporting an error to risk management (68%) or completing an incident report (60%).

• Few physicians believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45%) did not know if one existed at their organization.

• A majority (61%) reported using at least one informal mechanism to report an error to their hospital or healthcare organization, most commonly telling a supervisor or manager (40%) or physician chief or departmental chairman (38%). The survey indicated that physicians were more likely to discuss serious errors, minor errors and near misses with their colleagues than to report them to a risk management or to a patient safety official.

Only 30% agreed that current systems to report patient safety events were adequate.

When asked what would increase their willingness to formally report error information, physicians said they wanted: 1) information to be kept confidential and non-discoverable (88%); 2) evidence that such information would be used for system improvements (85%) and not for punitive action (84%); 3) the error-reporting process to take less than two minutes (66%); and 4) the review activities to be confined to their department (53%).

Patient Safety Act under development

In other news related to patient safety, the Department of Health and Human Services said It is currently developing a “proposed” regulations to implement the Patient Safety and Quality Improvement Act of 2005, authorizing the creation of new entities called Patient Safety Organizations (PSOs) that will collect, aggregate and analyze confidential information voluntarily reported by healthcare providers; such information is generally confidential and privileged in accordance with the Patient Safety Act.

HHS said that these PSOs will use this information to identify systemic and avoidable causes of risk in medical settings and to provide feedback to health care providers about successful approaches that reduce such risk and thereby improve patient safety and quality.

A call for FDA to regulate tobacco

The American Lung Association (New York) would like to add one more item to the FDA’s list of responsibilities. The association’s State of Tobacco Control 2007 report, an annual report card on federal and state tobacco control legislation and policies, assigns only Ds and Fs to the federal government, but says 2008 presents “an historic opportunity for Congress to make a dramatic impact on tobacco control across America by authorizing the FDA to regulate tobacco products.”

In a statement, the association said, “Strong, bipartisan legislation is pending in both the U.S. Senate and U.S. House of Representatives that would give the FDA authority over the manufacture, distribution, marketing and use of tobacco products.”

Bernadette Toomey, president/CEO of the association, said, “We need leaders to stand up and enact national changes that will prevent lung diseases such as lung cancer and chronic obstructive pulmonary disease, which includes emphysema and chronic bronchitis.”