Learning From Mistakes             Return to the Beginning

Most experts agree that adding safety systems to hospitals is the best way to reduce errors. But they are still grappling with how to best determine the exact number of errors that occur, and exactly what causes them. In the case of medication errors, the numbers reported in the IoM report are only the tip of the iceberg, according to the authors, because many mistakes go undocumented and unreported.

Fear of lawsuits and job loss, the deeply entrenched notion that professionals don't make mistakes, and the hierarchical nature of medicine (nurses, for example, hesitate to "tell" on doctors), keep people from coming forward when errors occur. While more than a dozen states have established mandatory reporting programs with varying policies, errors are not reported, according to Richard Croteau, MD, executive director for strategic initiatives at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

One reason is that most states do not regularly audit health facilities to ensure that all errors are reported, and they don't reprimand institutions that fail to reveal mistakes.

At the LDS Hospital in Utah, which developed one of the most sophisticated computerized drug-order systems in the country, administrators saw first-hand how important surveillance is in eliminating problems. Before they came up with the personnel and funding needed for surveillance, they were reporting six adverse drug events a year. While that is typical for U.S. hospitals, it is too few to get a good handle on the root causes of problems. Once LDS established a good monitoring system, their numbers soared to 487 events annually. Thanks to their new safety focus, the number is now down to fewer than 100.

Another problem is that not all programs include a way of analyzing the mistakes that do occur. At the JCAHO, experts believe that reporting needs to be coupled with a root-cause analysis.

Even stickier is the issue of who has access to potentially charged information, such as an analysis of who was involved in a mistake. According to Dr. Croteau, ideally the only groups to receive the information would be accrediting or oversight bodies such as state departments of health. They would use the analyses to learn from mistakes and then pass on those lessons.

Dr. Lawrence deeply believes in mandatory reporting, echoing the IoM report recommendations. But he doesn't believe that institutions can take on the issue without taking some action to protect employees from legal repercussions.

Other expert groups, including the Institute for Safe Medication Practices and the American Medical Association (AMA), oppose mandatory reporting. It appears not to provide the kind of data needed, according to Nancy Dickey, MD, past president of the AMA. And she believes that it may have the perverse result of driving errors underground.

The big-picture solution, many experts say, is for healthcare to take its cues from the commercial airline industry, which cut airline fatalities by 80 percent between 1950 and 1990. Instead of unrealistically expecting pilots to perform perfectly in the cockpit, the industry reduced fatal errors by using a combination of high-tech safety systems, rigorous pre-flight safety checks by a highly trained team of pilots, and a well-funded national, confidential reporting system.

The airline reporting system identifies crashes as well as "near misses." To help curb medical mistakes, the IoM recommends national mandatory, public reporting of "medical crashes" -- errors that cause death or serious harm. They also urge development of confidential reporting systems for "near misses" and other less harmful incidents.

However it happens, increasing reporting is a key part of reducing medication errors. Dana-Farber is in the market of looking for more errors to be reported, not less, according to Jim Conway, who became Chief Operations Officer of the beleaguered organization several months after Betsy Lehman died. Under Conway's leadership, Dana-Farber overhauled its systems for preventing medication errors and has taken a leadership role in the movement to improve hospital safety. Since 1995, Conway has spoken about the issue to more than 50 groups and institutions around the country, earning him a top award from the American College of Health Care Executives in 1999.