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Blame-free system increases medical error reports

By Kerry Grens

NEW YORK (Reuters Health) - Flagging medical errors through a system that emphasizes a lack of punishment and maintains anonymity yields more reports than a traditional method of reporting errors, a team of doctors has found.

After introducing the new system at a pediatric clinic in North Carolina, the number of reported mistakes jumped from five to 86 per year on average.

"Getting reports doesn't mean we're in an unsafe practice, it means we're addressing flaws to make us a better practice," said Dr. Daniel Neuspiel, the lead author of the study and the director of ambulatory pediatrics at Levine Children's Hospital in Charlotte, North Carolina.

Since 1999, when the Institute of Medicine released a landmark report estimating that nearly 100,000 Americans die yearly because of medical errors, health care organizations have ramped up their efforts to recognize errors and improve safety.

But many medical errors still go unreported, studies have found. Neuspiel said a fear of retaliation, coupled with cultural barriers to addressing mistakes, keeps people from reporting them.

"Despite all that's been done after the Institute of Medicine advice, the culture still largely persists, particularly in areas like outpatient care and in pediatrics where there generally is very little recognition that there are significant errors going on," Neuspiel told Reuters Health.

Neuspiel and his colleagues trained a "pediatric safety champion team" to implement a new reporting system in a large clinic in Charlotte, North Carolina.

Members of the team represented every part of the office, from the physicians and nurses to the office managers and front desk staff.

They educated employees of the practice about reporting, and emphasized that all reports would remain anonymous and no one would be punished for making a mistake.

By contrast, the traditional reporting system that had been in place was not anonymous and was frequently punitive, Neuspiel said.

The safety team met monthly to review the errors that the staff submitted, and to develop ways to fix the root problems.

In the last year of the old system, there were just five error reports. After two and a half years under the new system, however, the safety team had collected and reviewed 216 reports, most of which were submitted by doctors and nurses.

There were 68 cases of entering incorrect information on a patient's record, 27 instances of laboratory tests being delayed or neglected, 24 medication errors and 21 mistakes involving vaccines.

The team addressed three-quarters of the errors with changes in the practice. For instance, to prevent nurses from giving kids the wrong vaccine, the office implemented a policy to remove all distractions and other tasks from nurses while they are preparing the shots.

Neuspiel said the staff notified parents about any mistakes that could have harmed their child, such as if the child got the wrong dose of a medication.

"We would notify the parent and apologize and explain whether there was potential risk to the child or not. Fortunately we haven't had any errors causing serious harm to a patient," he said.

The reforms Neuspiel and his team brought to the practice are now a permanent part of the office.

He expects that this type of system would be easy to install in other outpatient practices.

"These types of errors are going on everywhere, so I'm hoping more practices will consider making changes," he said.

SOURCE: http://bit.ly/s81e7u Pediatrics, November 21, 2011.

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