Should patients and families be made aware when medical mistakes occur? Regardless of the increased exposure to litigation and negative publicity, healthcare risk managers
believe full disclosure on medical mistakes should be the hospital policy that rules the day, according to a survey released at a patient safety symposium last week in Dallas. The
symposium was sponsored by Partnership for Patient Safety (P4PS).
The survey presented 3,389 risk managers with five hypothetical scenarios drawn from real cases: a surgical mishap, an unneeded mastectomy due to an erroneous lymph node
diagnosis, two medication overdoses and a child who wandered away from a pediatric unit and was later found on a roof unharmed.
In responses that ranged from 57% to 66%, risk managers said that patients and families should be made aware of the errors.
One of the ways hospitals can integrate policies on full disclosure into their corporate culture is by making patient safety a board-level priority, says Julie Morath, chief
operating officer of Children's Hospitals and Clinics of the Twin Cities who spoke at the meeting.
She offered these tips on how hospitals can improve their patient safety initiatives:
- Educational session and materials designed to promote an understanding of how systems can be changed to reduce the potential for harm.
- A full disclosure policy to guide, support and direct staff who interact with patients and families following medical accidents.
- A blameless reporting system designed to encourage staff to report "near misses." Be careful with what the report is called, for example, instead of referring to it as an
"incident report" use a less accusatory term like "safety report." - Review and implementation of appropriate best practices that have been identified through the available research.
- Regular reports to the CEO and board of directors on patient safety progress.
P4PS is making the patient safety advice offered from industry leaders at the meeting available on CD ROM. P4PS also is hosting an online discussion on ways healthcare
providers can reduce medical errors at http://www.p4ps.com. Some of the themes that will be tackled include: - Cultural obstacles that impede organizational performance.
- Innovations in technology, informatics, decision support and knowledge management systems.
- Strategies for moving beyond blame-based safety policies to new models of learning and accountability; and
- The patient's role as partner in risk education.
Other tips on developing patient safety programs are offered in the News Monitor section of HPRMN's June 8 issue.
(Partnership for Patient Safety, Punnie Donahue, 314/496-9620, http://www.p4ps.com)