Are You Doing All You Can to Spot Medical Errors?

HealthLeaders Media Staff, June 25, 2009

Earlier this month, the 185-bed Doctors Community Hospital, located outside of Washington, DC, in suburban Prince George's County, MD, was fined by state health regulators who said the hospital failed to notify them that a patient had died and that at least seven others suffered serious injuries last year because of medical staff mistakes.

The fine was stiff: $95,000. However, the state officials agreed to reduce the penalty to $30,000, with the remaining $65,000 to be used to develop a patient safety program. Administrators at the hospital have subsequently acknowledged their failure to comply with the law and called the state's action a wake up call to examine patient safety procedures at their hospital, according to an article in the Washington Post.

Unfortunately, this hospital may not be alone in the reporting—or rather non-reporting—department. According to the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report, this may be a common occurrence. In its survey for the 2009 report of 622 hospitals with 196,462 respondents, AHRQ found several areas that hospitals could consider in improving their patient safety efforts:

Number of events reported. On average, most of the respondents within hospitals (52%) reported no adverse events in their hospitals in the past 12 months. It is likely that events were being underreported, AHRQ said. Event reporting was identified as an area for an improvement in most hospitals because potential safety problems may not be recognized or identified—and therefore not addressed.

Teamwork within units. This is the extent to which staff support each other, treat each other with respect, and work together as a team. It also was the area that had the highest positive responses (79%), which indicates it is a strength for most hospitals, the report noted. In addition, 86% agreed with the statement that when a lot of work needs to be done, everyone works together as a team.

Nonpunitive response to errors. This is an area with the most potential for improvement, the report noted. About 35% of those surveyed strongly disagreed or disagreed with this statement: "Staff worry that mistakes they make are kept in a personnel file."

Handoffs and transitions. This area also created some concerns, according to AHRQ. Only 41% disagreed or strongly disagreed with the statement that things fall between the cracks when patients are transferred.

According to AHRQ, the survey results are not really the endpoints, but the beginnings of starting a patient safety dialogue. Often the perceived failure of surveys to create lasting change is due to faulty culture of safety or nonexistent action planning. To move to a patient safety culture, AHRQ suggests these steps:

  • Understand the survey results.
  • Communicate and discuss the survey results.
  • Develop focused action plans.
  • Communicate action plans and deliverables.
  • Implement action plans.
  • Track progress and evaluate impact.
  • Share what works.

It may be a simple formula, but it could help provide a wake-up call to avoid a more punishing—and public—result down the line.

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