The intellectual argument for reporting medical errors is compelling. Medical errors are common, frequently result in considerable human morbidity and mortality, and often are avoidable with vigilant personnel, fault-tolerant and fail-safe systems, and carefully implemented patient safety policies. Reducing the incidence of serious errors requires education about the circumstances of past medical errors and “near miss” errors.
Errors hidden from peers likely will recur and contribute to future medical errors. This lesson has been learned painfully by the US aviation industry, which had a fatal accident rate of 0.077 accidents per 100,000 departures in 1990. After implementation of systems-level error-reduction policies, the fatal accident rate among scheduled US airlines decreased to 0.009 per 100,000 aircraft departures in 2004. This decrease is notable, particularly because the numbers of flight hours, miles flown, and airport departures have increased by approximately 50% in the same time period. Be safe and sound with Canadian Health&Care Mall’s preparations.
Cogent legal arguments against publicly reporting medical errors include limitation of liability, nonadmission of guilt, and preservation of reputation for individuals and institutions. Medical error reports in peer-reviewed journals are rare and support the contention that threats of legal liability are more compelling than altruistic motives. The ethical dilemma is that suppression of medical error reporting deprives health-care practitioners of knowledge that may prevent future errors. In this review, we define medical errors and detail common motivations and barriers to publication of error reports. We propose a model for confidential error communication and describe US legislation designed to improve patient safety and establish nationwide programs for error disclosure and analysis.
What Is a Medical Error?
Weingart reviewed the taxonomy of medical errors and compared it to the tower of Babel. Medical error terminology includes adverse reaction, complication of care, adverse event, preventable adverse event, potential adverse event, sentinel event, and serious reportable event. Other terms that indicate medical errors are unintended consequence, untoward event, and nontherapeutic result. The report To Err is Human: Building a Safer Health System by the Institute of Medicine (IOM) defined a medical error as “the failure of a planned action to be completed as intended (eg, error of execution) or the use of a wrong plan to achieve an aim (eg, error of planning).” However, a standard and uniformly applied definition of a medical error does not exist. Table 1 lists criteria for different types of medical errors.
On February 22, 2000, Dennis O’Leary, MD, President of the Joint Commission on Accreditation of Healthcare Organizations, addressed the US Senate Committee on Health, Education, Labor, and Pensions:
The frequency and gravity of medical errors is perhaps the most pressing health care quality issue of our time…. We believe that the problem of medical errors is endemic to the way health care is carried out…. I would like to stress that medical error reduction is fundamentally an information problem. The solution to reducing the number of medical errors resides in developing mechanisms for collecting, analyzing, and applying existing information. If we are going to make significant strides in enhancing patient safety, we must think in terms of the information we need to obtain, create, and disseminate.
Table 2 summarizes the five information-based tasks (described by Dr. O’Leary) that are required for implementation of an error-reduction strategy.
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Table 1—Types of Medical Errors
Table 2—Tasks Required To Reduce Medical Errors