Opinions and experiences of hospital leaders about State reporting systems were solicited from chief executive and chief operating officers of hospitals in six States with a variety of reporting systems: mandatory, nonconfidential mandatory, confidential and voluntary systems. 6 Analysis of reported errors have revealed many “hidden dangers” (near misses, dangerous situations, and deviations or variations) that point to system vulnerabilities, not intentional acts of clinician performance that may eventually cause patients harm. Reporting near misses (i.e., an event/occurrence where harm to the patient was avoided), which can occur 300 times more frequently than adverse events, can provide invaluable information for proactively reducing errors. Systems problems can be detected through reports of errors that harm patients, errors that occur but do not result in patient harm, and errors that could have caused harm but were mitigated in some manner before they ever reached the patient. To effectively avoid future errors that can cause patient harm, improvements must be made on the underlying, more-common and less-harmful systems problems 5 most often associated with near misses. Because many errors are never reported voluntarily or captured through other mechanisms, these improvement efforts may fail.Įrrors that occur either do or do not harm patients and reflect numerous problems in the system, 4 such as a culture not driven toward safety and the presence of unfavorable working conditions for nurses. Patient safety initiatives target systems-related failures that contribute to errors within the complex environment of health care. Nonetheless, reporting potentially harmful errors that were intercepted before harm was done, errors that did not cause harm, and near-miss errors is as important as reporting the ones that do harm patients. 2, 3 The IOM report also emphasized the importance of reporting errors, using systems to “hold providers accountable for performance,” and “provide information that leads to improved safety.” Conceptually these purposes are not incompatible, but in reality they can prove difficult to satisfy simultaneously 1 (p. This report emphasized findings from the Harvard Medical Practice Study that found that more than 70 percent of errors resulting in adverse events were considered to be secondary to negligence, and more than 90 percent were judged to be preventable. The focus on medical errors that followed the release of the Institute of Medicine’s (IOM) report To Err Is Human: Building a Safer Health System 1 centered on the suggestion that preventable adverse events in hospital were a leading cause of death in the United States.
Reporting errors is fundamental to error prevention.
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