In the late 1990s, as patients, reporters, and legislators began to appreciate the scope of the medical errors problem, the response was nearly Pavlovian: we need more reporting! This commonsensical appeal had roots in several places, including the knowledge that transparency often drives change, the positive experiences with reporting in the commercial aviation industry,1 the desire by many interested parties (patients, legislators, the media, healthcare leaders) to understand the dimensions of the safety problem, and the need of individual healthcare organizations to know which problems to work on.
I'll begin this chapter by focusing on reporting within the walls of a healthcare delivery organization such as a hospital or clinic. I'll then widen the lens to consider extra-institutional reporting systems. Further discussion on these issues, from somewhat different perspectives, can be found in Chapters 3, 20, and 22.
The systems to capture local reports are generally known as incident reporting (IR) systems. Incident reports come from frontline personnel (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred) rather than, say, from supervisors. From the perspective of those receiving the data, IR systems are passive forms of surveillance, relying on involved parties to choose to report. More active methods of surveillance, such as retrospective chart review, direct observation, and trigger tools, have already been addressed in Chapter 1, though I'll have more to say about them later in this chapter.
Although IR systems capture only a fraction of incidents, they have the advantages of relatively low cost and the involvement of caregivers in the process of identifying important problems for the organization. Yet the experience with them has been disappointing—while well-organized IR systems can yield important insights, they can also waste substantial resources, drain provider goodwill, and divert attention from more important problems.2
I believe that the following realities should frame discussions of the role of reporting in patient safety:
- Errors occur one at a time, to individual patients—often already quite ill—scattered around hospitals, nursing homes, and doctors' offices. This generates tremendous opportunity to cover up errors, and requires that providers be engaged in efforts to promote transparency.
- Because reporting errors takes time and can lead to shame and (particularly in the United States) legal liability, providers who choose to report need to be protected from unfair blame, public embarrassment, and legal risk.
- Reporting systems need to be easy to access and use, and reporting must yield palpable improvements. Busy caregivers are not likely to report if systems are burdensome to use or reports seem to disappear into the dark corners of a bureaucracy.
- Many different stakeholders need to hear about and learn from errors. However, doctors, nurses, hospital administrators, educators, researchers, regulators, legislators, the media, and patients all have different levels of understanding and may need to see very different types of reports. This diversity makes error reporting particularly challenging....