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Nonpunitive event-reporting system
is the key to patient safety
By Joan E. Shook, M.D.
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Dr. Joan
Shook with a patient |
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As the chief safety officer for Texas Children’s Hospital, it is
my responsibility to oversee the continued implementation of the
patient-safety program and increase awareness of patient safety
throughout the organization. Although no single activity will
accomplish this, it is widely accepted that successful
error-reduction strategies depend heavily on responsible
detection and open reporting of errors.
For physicians, the morbidity and mortality conference provides
a forum for discussion of adverse clinical outcomes – many of
which are caused not by error but rather the course of the
underlying disease. However, the presence of senior faculty
members can inhibit frank discussion of the possible role of
errors. Absent a forum that encourages and supports frank
discussion or a strong methodology for the reporting of errors,
silence prevails.
For Texas Children’s to arrive at the robust reporting system
needed to achieve open reporting of errors, several elements
must be in place. First, front-line clinicians, including
physicians, must be encouraged to report their errors.
Otherwise, it will be impossible to develop an effective
reporting system that collects large amounts of measurable data.
Because physicians are on the front lines where clinical care
takes place, they are often the first to realize that an
unexpected outcome has occurred. Reports from front-line
practitioners can best describe the specific conditions that led
to that error. Better error descriptions make possible more
effective analysis of the system-based causes of errors.
Analysis of aggregate data often reveals patterns associated
with errors. These patterns, in turn, point to systemic flows
and vulnerabilities that must be addressed to reduce the risk of
error.
The key to success for any event-reporting system is a
nonpunitive, system-based approach to error reduction. A robust
event-reporting system acknowledges the inevitability of human
error and understands that errors occur because people cannot
consistently outperform unsafe systems that bind and constrain
them. Event analysis is process-oriented rather than
outcome-oriented, and error-reduction efforts are not targeted
at the individual – the least manageable link in the error chain.
Error-reduction strategies, on the other hand, are designed to
strengthen the systems in which practitioners work to make it
difficult or impossible to err.
In working toward a robust event reporting and management system
at Texas Children’s, an IDS work group is examining the current
process and developing a method for future reporting. The next
steps will be to evaluate and select an electronic reporting
system for use across the entire IDS. Stay tuned as we continue
to strive to gain new information about preventable adverse
events.
Joan E. Shook, M.D., is chief safety officer and chief of
Emergency Medicine at Texas Children’s Hospital and professor of
pediatrics and head of Pediatric Emergency Medicine at Baylor
College of Medicine.
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