Federal Aviation Administration investigations of passenger airline crashes are painstaking analyses of the root causes of failure. In highly publicized reports, blame is assigned when possible. Follow-up is usually rigorous, focused on preventing a recurrence of disaster.
In healthcare, with the equivalent of a jumbo jet's worth of patients dying every day from preventable mistakes, we have calls for voluntary reporting of errors but only confidentially so that nobody suffers after they unintentionally kill or maim someone.
The most recent example of this whitewashing of what should be a national scandal is a bit of public relations puffery offered up by Sen. James Jeffords (Ind-Vt.). The legislation seeks voluntary reporting of errors coupled with a guarantee of confidentiality. A similar bill passed the Senate last year but failed to get House support.
Five years ago, the Institute of Medicine called for manda-tory reporting of all medical mishaps and public disclosure of the most egregious errors. In 2001, the Joint Commission on Accreditation of Healthcare Organizations ordered hospitals to tell patients when they made an error resulting in injury. But a new survey by the Journal of the American Medical Association found that 69% of 203 hospital executives said manda-tory reporting that doesn't protect the confidentiality of doctors and other hospital staff deters rather than promotes the self-reporting of errors. The executives believe such a system encourages lawsuits and would have no effect on patient safety, presumably because people would simply continue to lie about events they had witnessed.
This is the same sort of feeling expressed by 1,700 respondents to a January survey by the American Association of Critical-Care Nurses, which found that 84% of surveyed doctors and 62% of the nurse respondents saw co-workers take "shortcuts that could be dangerous to patients." Fewer than 10% of doctors, nurses and other health providers surveyed directly confront their colleagues about their concerns.
Everybody is afraid of reprisals for coming clean about the sorry state of patient safety in this country. Those fears are crystallized by cases such as that of Virginia Mason Medical Center in Seattle, which won kudos for issuing a highly publicized mea culpa after the agonizingly slow death of a woman patient who had been mistakenly injected with a cleaning solution in November 2004. The hospital is about to be sued by her relatives, who said last week that the apology was a "public relations stunt." Given the seriousness of the event, a large settlement was in the offing whether the hospital went public or not. The hospital's immediate move to publicize the event and change procedures to prevent a recurrence should still be applauded.
Currently, 18 states require healthcare facilities to report medical errors or adverse events to a medical board or other government entity. These laws, however, lack consistency in what errors are reported, who must report (the hospital or an individual practitioner) and whether to protect whistle-blowers. And it seems nobody is really complying anyway. A study of New York's system of tracking errors found that five years into the program it is an abject failure. Relatively few events are being reported by hospitals and a third of hospitals haven't suspended a doctor for more than 30 days in the past 12 years.
Studies show people usually don't sue because of avarice. Most are angry that they were injured, no longer can work and/or believe the providers involved don't care enough about what happened. If providers want the public to become more forgiving when problems arise, they need to show that they're actively seeking to protect patients from harm. The place to start is mandatory public accountability for errors.
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