Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Collaborative approach to harm reduction
- Michael R Finn (12 March 2004)
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Engaging everyone in change
- Kirstine Magtengaard (13 March 2004)
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National reporting system
- Torben Kitaj (18 March 2004)
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Disclosing medical errors: any limits?
- Temidayo O. Ogundiran (17 May 2004)
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Michael R Finn, Nurse Unit Manager Freemasons Hospital, East Melbourne Victoria Australia 3002
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The move by the National Patient Safety Agency (NPSA) to provide nationwide analysis of errors and system failures which compromise the safety of patients as reported by Katikireddi (1) should be applauded as a significant move forward for the health care industry. The ability to identify, and develop strategies to remedy these issues will ultimately lead to a safer environment in which to provide care. As many errors are recurrent, and often based on a background lacking sound systems and barriers to prevent their occurence, it is essential that the learning of one organisation be shared with many. All too often we hear of similar errors occuring in competing healthcare organisations, yet all have invented a different 'wheel' to fix the problem. There is little or no learning unless it directly occurs within your own organisation. If a more collaborative approach can improve this, then the organisation, healthcare providers, and ultimately patients benefit. Presently in Australia, a similar approach is being taken to tackle the difficult issue of medication related harm to patients. The National Medication Safety Breakthrough Collaborative, funded by the Queensland Safety and Quality Council, comprises fifty hospitals in the first wave, with the core aim to reduce harm in patients by 50%. All participating organisations have determined specific individual aims, depending on localised issues, but with the core aim as the lynchpin. It is envisaged that by determining issues related to harm caused to patients by medications, that strategic national recommendations could be developed. This is a vast improvement on the individualistic 'wheel making' that agencies currently undertake. We must learn from each other. The mistakes and errors made by one are knocking at most organisations' doors, waiting for the right conditions to enter. By working towards a common goal we, as in the case of the NPSA, can aim to improve the environment in which we work, and provide improved outcomes for patients by reducing harm. 1) Katikireddi V. National reporting system for medical errors is launched. BMJ 2004;328:481. Competing interests: None declared |
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Kirstine Magtengaard, Project Coordinator Victorian State Trauma Registry, 3181, Australia
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The news article by Vittal Katikireddi describes the introduction the National Reporting and Learning System (NRLS). This system was developed by the National Patients Safety Agency (NPSA) in 2001 to tackle the problems of adverse events in the NHS(1). The Harvard Studies first illustrated the significance of adverse events in health care systems in the early 1990’s (2,3). It was estimated that a stunning number, of as many as 44,000 to 98,000 Americans every year lost their lives as a result of adverse events occurring during their hospitalisation and even more were permanently disabled. The report from the US Institute of Medicine following these findings identified several reasons for why these human errors were occurring in such huge numbers, identifying the blaming of people rather than blaming the systems as a major obstacle in making organizations learn from their mistakes(4). The introduction of the NRLS shows that some of the lessons learnt in United States are being considered in health policy today. Above all the NRSL have ensured anonymous reporting to make the system an effective non- blaming learning-tool for the health system as a whole. However, the introduction of NRLS using a Top-Down organisational approach may cause problems in engaging health professionals at all levels and achieving their compliance to NRLS guidelines. The NRLS has been developed with a focus on creating a comprehensive system where valid data can be collected in order to make observations of problematic trends in health care procedures. Less focus has been put on how to ensure that health professionals will actually use the new system. Educating health professionals in the usefulness of the system, and engaging a medical culture largely based on autonomous decisions and traditional ways of doing things, will be essential for a successful implementation of the NRLS. It should be transparent to every health professional why the system is a good idea as well as offer incentives to use the system. These could include extensive feedback mechanisms to health professionals who report incidences. It is also important for the health care sector to understand and advocate the necessity of adjusting quality measures to local organizations instead of promoting package solutions on a national basis. The understanding and commitment to a quality tool, such as the NRLS needs to happen at all levels of health care for the system to be effective. 1. Katikireddi V. National reporting system for medical errors is launched. BMJ 2004; 328 (7438): 481-a. 2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients – results of the Harvard medical practice study I. NEJM 1991; 334: 370-376. 3. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients – results of the Harvard medical practice study II. NEJM 1991; 334: 370-376. 4. Kohn CT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington: National Academy Press, 1999: 1-6. Competing interests: None declared |
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Torben Kitaj, Editor Journal of the Danish Medical Association
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According to BMJ Vol. 328, 28 February 2004, p. 481 the world's first national reporting system for medical errors was launched this week, i.e. the last week of February. I just want to notify you that the Danish Parliament in June 2003 passed a law about Patient Safety. The Danish national confidential incident reporting system was launched in January 2004. Competing interests: None declared |
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Temidayo O. Ogundiran, Lecturer/Consultant Surgeon Department of Surgery, University of Ibadan & University College Hospital, PMB 5116, Ibadan, Nigeria
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Abstract In the news section of the February 28, 2004 edition of the BMJ, Vittal Katikireddi reports that “the world's first national system for collecting reports of health system failures and any error that compromises patients' safety” had been launched by the British health minister Norman Warner (1). The system tagged the “national reporting and learning system (NRLS)”, and developed by the National Patient Safety Agency (NPSA), an agency of the National Health Service (NHS), is aimed at improving patients' safety by collecting reports from health professionals across England and Wales. The task of the NRLS is to extract information about medical errors from existing local risk management systems or receive direct online reports from NHS officials in an anonymous form leaving out the names of involved patients and staff. Commenting on this initiative, Susan Williams, one of the chief executives of the NPSA explains that errors do occur in complex health care systems regardless of the people involved. According to her, the ratings of hospitals or trusts will not be published but the NRLS will work with the “Commission for Healthcare Audit and Inspection to help them make a judgment about how hospitals and trusts are doing with regard to patient safety.” Comment The summary above illustrates a further step in the growing call for health care professionals to disclose medical errors that occur in clinical care. There are no other categories of health care professionals to which this call is more intense and direct than to physicians who are involved in routine clinical practice. Many calls have been made and articles written that emphasize the necessity for physicians to disclose to their patients any mistake or negligence committed in the process of medical management especially if such omission or commission results in material harm to the patient. Some health institutions have established risk management systems or policies which proactively take the initiative to inform the affected patients and their families (2). The British system of creating a national database for medical errors adds a new but not- unexpected dimension to the “evolution of ensuring quality” (3) in the health care organization. Wu et al define a medical mistake as “a commission or an omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences”(4). They categorize medical errors into two classes: those that occur as a result of flaws in the medical system (system errors) and those that derive primarily from deficiencies in the physician’s knowledge, skill or attentiveness. Ethical reasons that have been advanced in support of full disclosure of medical errors to patients include the physician-patient relationship which is built on trust, respect for persons and truth telling. The consensus opinion appears to be that all errors should be disclosed to the patient partly because of the apparent soothing effect such disclosure has on the patient and the disclosing physician, and the overall benefit to the system. Moreover, documentation is likely to result in a decline in the number of errors committed. One disturbing consequence of this practice is that a cataloguing of errors committed by a physician or in an institution could lead to misjudgment of the physician’s skill and expertise on one hand, and to erosion of confidence in the medical system on the other hand. This point becomes more relevant in cultures where traditional beliefs and practices that are not based on sound science hold sway against orthodox western medicine. Mistakes are by their nature inadvertent acts that no right thinking professional deliberately commits. It is enough that an unplanned act of omission or commission that injures the patient is acknowledged and due disclosure made where and when necessary. Making it a “notifiable act” that some official organ (at hospital or provincial or national level) is now mandated to look for and collate elevates it beyond what it is – an error, to what it should not be, but could potentially become — a stigma. This trend is likely to exacerbate defensive medical practices and erode physicians’ trust in their patients. Moreover, the trend does not seem to take into account the structure of the learning curve especially in surgical practice and the role that the established tradition of morbidity and mortality meeting plays in lessening the number of such errors. Furthermore, there may be a tendency to over-report complications of procedures as medical errors because of the difficulty to determine how much the clinician has contributed to the development of those complications. A surgeon who injures and repairs a vital vessel which is delicately encased within a tumor he is removing is obligated to disclose this event as an error though it could be an anticipated and likely complication of the procedure. Where does he draw the line between a likely but uncommon complication and a surgical error? Has he “covered up his error” if he duly informs his patient (as he would normally do) but does not disclose it to any official organ of the hospital or trust? Answers to these questions call for a consideration of the context. A circumstance in which reliable and sensitive pre-operative investigative tests have identified the vessel and its course should not be assessed with the same yardstick as a situation where such pre-operative delineation is not feasible. It follows from this, then, that though the physician has a moral duty to inform his patients of unintended occurrences during treatment, the form, nature and content of disclosure cannot be the same across board. There are institutional, geographical and cultural variations that need be put in proper perspective for any general rule of disclosure and documentation to apply. The tendency to apply ethical considerations to enforce professional rules ought to be tempered by an appreciation and practical understanding of socio-cultural values and consequences. The need to tell the truth and disclose all necessary information to patients is ethically incontrovertible in abstract theory; however, caution should be exercised in not making the process more injurious to the patient and the system in practice. References: 1. Katikireddi V. National reporting system for medical errors is launched.BMJ 2004;328:481 2. Kraman SS, Hamm G. Risk management: Extreme honesty may be the best policy, Ann Intern Med 199; 131 (12): 963-7 3. Cranfill LW. Approaches for improving patient safety through a safety clearinghouse,J Healthc Qual. 2003 Jan-Feb; 25(1):43-7 4. Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med 1997; 12:770–5. Competing interests: None declared |
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