Physicians tell colleagues but don't report errors

Physicians are willing to share knowledge about harmful errors and near misses with their institutions but find current systems to report and disseminate this information inadequate. So they rely instead on informal discussions with colleagues, according to a survey of more than 1,000 physicians, as reported in the Medical Liability Monitor (3/2006). As a consequence, much important information remains invisible to institutions and the health care system, investigators concluded, noting the importance of gathering comprehensive information about all errors and near misses to understand and prevent medical errors. Results of the survey, which focused on attitudes about communicating errors as well as experience with errors, were published in the February/March issue of Health Affairs.

More than half of respondents indicated that they had been involved with a serious error, about three quarters with a minor error, and two thirds with a near miss. More than half agreed that “medical errors are usually caused by failures of care delivery systems, not failures of individuals.” Most physicians agreed that to improve patient safety, they should report errors to their hospital or health care organization, particularly if they were serious. Almost all (95%) agreed that to improve patient safety they needed to know about errors in their institutions, and 89% agreed that they should discuss errors with colleagues.

A full 83% had used at least one formal error reporting mechanism, most often by reporting an error to risk management or completing an incident report (reporting an error to a patient safety program was also considered a formal mechanism). Sixty one percent of respondents had used at least one informal mechanism to report an error, most often telling a supervisor, physician chief, or departmental chair. But physicians were more likely to discuss all kinds of errors and near misses with their colleagues than to report them to risk management or a patient safety program. Few physicians believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45%) did not know if their institution had such a system.

Asked what would increase their willingness to formally report error information, physicians’ top priorities were that information be kept confidential and nondiscoverable (88%), having evidence that information would be used for system improvements (85%), having a system that was not punitive (84%), having an error reporting process that takes less than 2 minutes (66%), and for the system to be local to their unit or department (53%).