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Preventable Hospital Deaths Can Be Reduced by Encouraging Error Reporting

by Clif Boutelle, SIOP Public Relations 

Creating a learning-oriented culture within hospitals and carried out by charge nurses and leaders at the point of care is a key to patient safety.
           
People go to hospitals to be treated for an illness or for corrective surgery with the expectation they will return home in much better health than when they entered the medical facility.
 
The reality, though, is that many may never recover or return home. A 2009 study by Hearst newspapers estimated the death toll from preventable medical mistakes is nearly 200,000 annually in the United States.
 
That’s not much different than a 2004 report from HealthGrades, a healthcare quality organization, showing that in the 3 previous years, about 195,000 Americans died each year; the result of preventable medical practices in hospitals.
 
One way of lowering those numbers is to reform the way errors are reported, which in this country is often beset by complex and contentious procedures, according to the reports.
 
Improvements in hospital safety practices begin with the reporting of errors and potential mistakes in the care of patients, said Dana E. Sims, who focused a study on the influence of a learning-orientation culture within an organization and trust in leadership on workers’ willingness to formally report and document errors.
 
Sims, who conducted the study for a doctoral dissertation at the University of Central Florida in 2009, presented her findings earlier this month at the Society for Industrial and Organizational Psychology’s annual conference in Atlanta.
 
There is no uniform reporting among states in regard to releasing information about mistakes. In March the inspector general of the Department of Health and Human Services issued a report that indicated hospitals are not consistent in gathering information about preventable medical errors because of inadequate hospital data and poor internal tracking of medical errors by hospitals themselves.
 
Accurate reporting of errors depends upon whether organizations encourage, support, and follow up the documentation of errors and practices that can harm patients. Also, compiling information relies heavily on front-line employees, nurses, and medical staff being able to report mistakes within a nonthreatening culture.
 
“It’s important to identify and adapt procedures that are unsafe and potentially can lead to serious mistakes,” said Sims. “If hospital administrators are unaware of mistakes and unsafe practices, they cannot do anything about them.”
 
Too often healthcare workers believe error reporting is a sure path to trouble that will result in blame and punishment to those involved. On the other hand, some hospitals will avoid finger pointing and instead take a holistic view of where the systemic failure may have occurred, said Sims.
 
Her study of care units within two hospitals found that organizations and leaders who promote a “learn from our mistakes” culture may bolster employees’ decisions to openly discuss errors.
 
“A smart organization knows that employees are aware of practices and incidents on the front line that the administration does not want to hear. But the administration needs to encourage employees to report them anyway to avert disaster,” Sims said. Sometimes top leaders are too insulated from what is happening within the organization, she added.
 
“In the long term, hearing what employees have to say can save lives as well as prevent expensive lawsuits and damages to a hospital’s reputation,” she said.
 
She found that perceptions about the organization are the strongest predictor of whether employees’ tend to document errors.
 
Establishing an organizational learning climate is important to sound reporting practices, said Sims. An organizational climate is a shared perception by workers of what is valued and expected in the work environment based upon the norms, policies, and procedures set by the organization.
 
Without those organizational standards, teams tend to make excuses, become defensive, and punish and blame others. Instead, an environment should be promoted where mistakes are viewed as an opportunity to improve team performances and openly discuss errors and potential mistakes, she said in her SIOP presentation.
 
The most common hospital mistakes are shortcuts or workarounds that medical staffs use in an effort to be more efficient in their work. Some of these basic at-risk behaviors could include failure to properly identify patients or to verify prescription dosages and inaccurate documentation of vitals, Sims said.
 
These are often done by experienced nurses who have handled these kinds of task previously and are convinced that a shortcut is acceptable. But in most cases it is not the right thing to do.
 
A blaming culture is not good for the organization. “Human mistakes are different than reckless practices,” Sims pointed out. “Sometimes in healthcare, with its accompanying stresses, there is a propensity to work around procedures in an effort to be more efficient. Rules and procedures are there for a reason and are intended to increase patient safety,” she added. 
 
“Individuals have a personal responsibility when they engage in those workarounds. While the organization needs to make clear that they are also accountable for reckless behavior, it also needs to identify internal practices that might be encouraging those work arounds to be used,” Sims said.
 
Hospitals can benefit by supporting employees who report practices that can lead to serious errors and using those reports to improve procedures. Providing good coaching and mentoring and making system changes will make a difference, Sims said.                       
 
One surprise Sims found in her study was a difference between an organizational-directed learning environment and a leader-promoted environment. Leaders, said Sims, are those people responsible for units within the organization.
 
“Based upon past research, I didn’t expect there to be much difference between perceptions of the leader and the organization, but the nurses I talked with said there often is a difference. Unit leaders have varying leadership styles and ways they interpret or put into practice organizational policies and procedures. Some are unwavering in following the procedures while others are more relaxed. In short, some filter the organizational policies,” Sims said.
 
“Healthcare organizations should place increased emphasis on what is done with the information gathered from error reporting systems,” Sims’ study concluded.
 
“Specifically, organizations must ensure that employees know they are being heard, that systemic problems identified via error reporting are addressed by the organization, and that employees who admit to and/or identify errors are helping the organization to create a climate of safer medical care,” she said.
 
Further, leaders at the point of care play an important role in their team’s willingness to document errors. Organizations must ensure their leaders have the skills necessary to reinforce learning-oriented responses to errors within their units, Sims said.
 
Without these (and other) changes, needless, avoidable deaths will continue unabated in the nation’s hospitals and care facilities.