A new study conducted at a pediatric clinic in Charlotte, North Carolina, discovered an increase in reported medical errors after the implementation of a blame-free reporting system. As an increase in reporting generally helps to improve patient safety, this is promising news.
The study was led by Dr. Daniel Neuspiel, director of ambulatory pediatrics at Charlotte's Levine Children's Hospital. Neuspiel and his team found that a blame-free reporting system greatly increased the number of reported medical errors. In a blame-free system, medical providers and other staff members make anonymous error reports and are considered immune from punitive measures. In the year before the system was implemented, there were five medical errors reported at the clinic in the study.
Implementing a Blame-Free System
To implement the blame-free error reporting system, Neuspiel and his team trained a "pediatric safety champion team" composed of physicians, nurses and office staff to collect data from the system. This team educated other employees about the new blame-free system, emphasizing that errors would be reported anonymously and would not result in punishment.
In the two and a half years after the system was put in place, there were 216 reported errors, an average of 86 per year. Nurses, physicians and other medical providers initiated most of the 216 error reports, though all medical clinic employees were encouraged to use the system. Incorrect patient data entry accounted for 68 of reported errors, lab mistakes accounted for 27 errors, medication mistakes 24 errors and vaccine mistakes 21 errors. More than 75 percent of these error reports resulted in clinic policy changes.
Good News for Patient Safety
The focus on reducing medical errors and implementing better error reporting systems was spurred by the Institute of Medicine's 1999 report To Err Is Human, which found that 44,000 to 98,000 Americans died in hospitals each year due to preventable medical mistakes. Though he believes that some medical errors still go unreported due to fear of retaliation, medical malpractice suits or a medical facility's culture, Neuspiel and his team found their blame-free system increased error reporting and believe it would be effective in identifying areas for safety improvement and catalyzing safety changes in other medical facilities.
Blame-free medical error reporting systems ensure anonymity and immunity from punishment for reporters and could increase error reporting at medical facilities, which would help identify areas that need improvement. However, until hospitals and other medical providers implement better error-reporting systems, patients will still be at risk of preventable medical errors. If you or a loved one have been the victim of a medical error, please contact an experienced personal injury attorney.
