The Fear of Information

Learn from your mistakes. That ubiquitous tenet of quality improvement theory inevitably surfaces in conversations between supervisors and subordinates, parents and children, coaches and players . . . and healthcare leaders and caregivers. That's the whole premise of adverse event reporting—to document errors and other flaws in patient care to help create safer practices and prevent those adverse events from happening again.

So do U.S. hospitals generally have adverse event reporting systems in place? Yes, according to an extensive new study. Are they actually using the data to effect improvements? Well, that's where the trouble starts.

The study, "Adverse Event Reporting Practices by U.S. Hospitals: Results of a National Survey," found that centralized systems for collecting reports on adverse events are almost universal—more than 94% of some 1,600 hospitals reported having such a system in some form. But the survey—funded by the Agency for Healthcare Research and Quality and conducted by researchers from AHRQ, the RAND Corporation, and The Joint Commission—also provided some less-than-encouraging findings:

• Although nearly every hospital reported having an adverse event reporting system, only 21% fully distribute and consider summary reports on the reported events.
• Slightly less than a third of hospitals have established environments that support adverse event reporting. The study defines a "supportive environment" as one that allows for anonymous reporting for all adverse event reporters and one that always keeps identities private for reporters who do choose to identify themselves.
• Only 13% have broad staff involvement in adverse event reporting. The study found that 96% of reports are submitted by nursing staff members.

The bottom line is that the "learning from mistakes" part of the equation is largely getting lost. "There's a lot of reporting going on, but not much being done with the information generated," says James Battles, PhD, senior service fellow for patient safety at AHRQ and one of the study's researchers.

OK . . . so why not? In a competitive healthcare landscape of increasingly savvy consumers—a landscape in which quality is supposed to be a market differentiator—why wouldn't a hospital want to actively utilize such data to improve its care processes, if only for its own self-interest? There are plenty of answers to that question, of course, but the overarching reason may be the most basic of all: fear.

"One of the big fears we get is that in many cases, hospitals have used event reporting for disciplinary action," says Battles. "We've got to create a more supportive environment where the information is used for learning, not for discipline or risk management issues." What's more, Battles adds, there's an "increased fear of sharing information that could be used against the institution."

One glimmer of hope in mitigating that fear, Battles says, may be patient safety organizations. In November, the U.S. Department of Health and Human Services published the final rule for the establishment of PSOs, initially authorized by the Patient Safety and Quality Improvement Act of 2005. The rule goes into effect later this month. PSOs are designed to remove the fear of disciplinary action or legal liability felt by both clinicians and healthcare organizations by providing a confidential place to which providers can report adverse events and other information for analysis. PSOs can then offer feedback to provider organizations for quality improvements.

Whether PSOs can significantly improve healthcare quality and safety remains to be seen. I suspect the reluctance to utilize reporting systems may be deeply ingrained in many cases, so the promise of anonymity and protection from sanctions may need some time to take hold. But even small steps toward a more productive use of adverse event data would be welcome. "The big push moving forward is how to make these hospitals' event reporting systems more useful as a learning tool," says Battles. "It shouldn't be just an exercise to fill a requirement of accreditation."