National reporting system for medical errors is launched
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7438.481 (Published 26 February 2004) Cite this as: BMJ 2004;328:481
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Disclosing medical errors: any limits?
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
Competing interests: No competing interests