How to beat the medical blame game

Nonpunitive systems yield more medical error reports, study finds

A reporting system that uses nonpunitive measures and emphasizes anonymity can identify more medical errors than traditional reporting methods, according to a study in Pediatrics.

For the study, researchers trained a "pediatric safety champion team" of medical and administrative staff to implement a new reporting system in a large pediatric clinic in North Carolina. The team discussed reporting practices with employees and emphasized that all reports would be anonymous and not carry a risk of punishment, unlike the clinic's traditional reporting system, which was not nameless and often was punitive. The team met monthly to address errors and develop solutions.

According to the study, the traditional reporting system over its last year collected five error reports. Meanwhile, the new method enabled the team to collect and review 216 error reports, including 68 cases of incorrect information entered on a patient's record, 27 cases of laboratory tests being delayed or neglected, 24 drug errors, and 21 mistakes involving vaccines. On average, the number of reported mistakes at the clinic climbed from five to 86 annually, the study found.

"Getting reports doesn't mean we're in an unsafe practice, it means we're addressing flaws to make us a better practice," study author Daniel Neuspiel said. According to Reuters, the team addressed 75% of identified errors. For example, to prevent nurses from administering the wrong vaccine, the clinic removed potential distractions while they were prepping the shot.

Neuspiel said many medical errors are not reported because employees fear retaliation and face cultural barriers to addressing their mistakes. However, he said a similar reporting system to the one in the study likely would be easy to implement at other practices (Grens, Reuters, 11/21).

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