The Patient Safety Collaborative

Making a difference - Prevention Systems for Patient Safety

Learning

Characteristics of an Ideal Reporting System for Learning
• The intent and goal of the reporting system are clear to all interested parties.
• Active leadership support is ensured at all levels.
• Reports are accepted from all interested parties.
• Reports are confidential and identifying information has been removed.
• Reports are used for prevention, not punishment.
• Reports are analysed by technically expert peers, from multiple perspectives.
• Reporting is easy to do and captures rich detail.
• Reporters and larger interested communities receive timely feedback.
• Pilot testing and prototyping of the system takes place before large scale roll-out occurs.

Analysis and Feedback

Successful error reporting systems are analysis and feedback systems. The key to their success starts with a highly visible ability to properly analyse cases and recommend changes to those who are empowered to implement them. Experts in the field of patient safety report that understanding the “root” of the problem and the “contributing” factors are winning strategies; counting errors and comparing performance are not.
Feedback to key decision makers and those who report is the second part of all successful error reporting systems. The CDC and FDA in the USA have found that lack of feedback was one of two main reasons for failed “mandatory” systems.
Experience with other reporting systems for improving safety demonstrates the importance of closing the feedback loop. Timely and usable feedback is crucial in making the system useful to those who report. Therefore, reporting formats should include both free-text narrative and standardized information as well as indicate how those who report can use the feedback.

The Ethics of Disclosure

Bioethics for clinicians: 23. Disclosure of medical error
Philip C. Hébert* , Alex V. Levin and Gerald Robertson

Abstract
ADVERSE EVENTS AND MEDICAL ERRORS ARE NOT UNCOMMON. In this article we review the literature on such events and discuss the ethical, legal and practical aspects of whether and how they should be disclosed to patients. Ethics, professional policy and the law, as well as the relevant empirical literature, suggest that timely and candid disclosure should be standard practice. Candour about error may lessen, rather than increase, the medico-legal liability of the health care professionals and may help to alleviate the patient’s concerns. Guidelines for disclosure to patients, and their families if necessary, are proposed