Health Care Provider Use of Private Sector Internal Error-Reporting Systems

The Role for Leaders of Health Care Organizations in Patient Safety

We review what leaders of health care systems, including chief executive officers and board members, need to know to have "patient safety literacy" and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone "at-risk behavior." A business case can be made for investing resources into systems that produce good outcomes reliably. Leaders must see patient safety problems as problems with their system, not with their employees. Leaders need to give providers information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement. Improving systems should produce better long-term results than educating workers to be more careful.

Medical error and decision making: Learning from the past and present in intensive care

BACKGROUND

Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

PURPOSE

The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

DATA SOURCE

Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

FINDINGS

Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

CONCLUSION

It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

Excess cost and length of stay associated with voluntary patient safety event reports in hospitals

This study estimates excess cost and length of stay associated with voluntary patient safety event reports at 3 hospitals. Voluntary patient safety event reporting has proliferated in hospitals in recent years, yet little is known about the cost of events captured by this type of system. Events captured in an electronic reporting system at 3 urban community hospitals in Portland, Oregon, are evaluated. Cost and length of stay are assessed by linking event reports to risk-adjusted administrative data. Hospital stays with an event report are 17% more costly and 22% longer than stays without events. Medication and treatment errors are the most expensive and most common events, representing 77% of all event types and 77% of added costs. Ninety percent of events result in no measurable harm. Patient safety events captured by voluntary event reporting reflect significant waste and inefficiency in hospital stays.