Doctors want to learn from each others’ mistakes, but concerns about confidentiality and retribution make them leery about formal reporting systems, according to a recent survey. As a result, “much important information remains invisible to institutions and the health care system.”
The survey, commissioned by the federal Agency for Healthcare Research and Quality (AHRQ), questioned 1,082 physicians and surgeons in rural and urban areas of Missouri and the state of Washington.
Almost all (95%) physicians agreed that they need to know about errors to improve patient safety, but only 30% said that systems for reporting and disseminating error information are adequate. Instead, most discuss mistakes and near misses informally with colleagues or supervisors. Thus “important information about medical errors and how to prevent them is not aggregated for analysis and systematic improvement,” the researchers note in Health Affairs (2008;27:246-255).
The observation is particularly significant in light of another survey finding: A majority of the doctors (54%) believed that “medical errors are usually caused by failures of care delivery systems, not failures of individuals.” That implies that improved safety depends more on institutional responses than on training.
Asked what an appropriate system might look like, physicians said they wanted:
- Information to be kept confidential and shielded from scrutiny by plaintiff’s lawyers if a malpractice claim arises (88%);
- Evidence that reports would be used for system improvements (85%) and not for punitive action (84%);
- Follow-up proceedings to be confined to the specific hospital department (53%); and
- Minimal paperwork so that filing a report would take less than two minutes (66%).
“These findings work to create error-reporting programs that will encourage clinician participation,” notes Carolyn M. Clancy, MD, AHRQ director.