Project 1. Evaluating Tools That Facilitate Reporting, Surveillance, and Analysis of Medical Errors/Adverse Events
Although iatrogenic injury causes substantial harm, comparatively few data are available regarding how to best foster environments in which individuals can learn from their mistakes, or regarding how hospital systems can implement systematic error prevention strategies. To advance our collective knowledge about developing systems that prevent and buffer errors, we must gather information about the types and causes of injuries associated with them. Lack of this information is a serious impediment to hospitals committed to improving patient safety.
Incident and error-reporting systems are not widely used, especially by physicians, due to cultural barriers, time constraints, shame, and fear of legal action or retribution. Tools to collect and analyze confidential data on incidents and errors, and then provide actionable feedback, will foster learning and have a substantial impact on patient safety. Factors essential to an effective reporting system are: 1) safety and empowerment for individuals with 'domain expertise'- those with intimate knowledge of the daily work environment and direct experience with a medical error; 2) non-threatening investigation and analysis, performed by individuals skilled at finding contributing factors; 3) pooling of reported data to facilitate trend analyses and prioritization; and 4) leadership backing of non-punitive reporting, investigative analysis, and implementation of improvement strategies.
In addition to problems with getting providers to use reporting systems, a key issue has been that our tools to analyze and learn from the errors and adverse events that do get reported are insufficient. To address this issue, we will collaborate closely with the Risk Management Foundation of the Harvard Medical Institutions, Inc. (RMF), which is a national leader among healthcare organizations in investigating, analyzing and coding adverse events leading to malpractice claims. Recognizing that learning from errors is indispensable to an injury-prevention strategy, the RMF has developed a model adverse event reporting system. While the RMF is integrated with the hospitals in the Partners HealthCare System, it is also removed from hospital management and can be a neutral data repository detached from the reporter's institution. The RMF has committed the resources of its experienced analysts to creating an enhanced classification, analysis, and stratification scheme of medical errors and a web-enabled system for reporting.
