Preventable Error Reporting Hindered by Fear of Reprisal

"On another level, if the reporting system is not oriented towards improving quality and transparently and safety then the reporting system is perceived as a 'gotcha!'" 

The report notes that new reimbursement models that diverge from fee-for-service and instead reward outcomes and patient satisfaction create an even greater need for strong infrastructures to collect accurate data and address patient safety concerns.

The report urges hospitals to:

• Focus on accountability for quality and safety as part of a strong and just culture.
• Build protective structures that encourage reporting quality and safety concerns.
• Compile transparent, accurate data and reporting to internal and external oversight bodies.
• Act on quality and safety concerns.
• Foster teamwork and open communication.

Even the best safety and reporting infrastructures may be stymied by an unwritten code of silence among clinicians and administrators, Angood says.

"The majority of care in this country is provided in hospitals of 300 beds or so and a lot of them are in smaller communities," he says. "It goes back to the human behavior piece. If you are going to work with the folks you see at the gas station or out shopping are you going to report each other out? Likely not."