Creating a Good System to Report Medical Errors - Assignment Example

Introduction A medical error is an error due to inapt method of treatment for a patient without knowing his history or the apt prescribed care carried out incorrectly. The consequences of medical mishaps are fatal. Institute of Medicine (IOM, 2000) has reported 44,000 to 98,000 deaths in a year in United States solely due to serious medical errors. The public awareness of medical errors in health care management has triggered many aspects of research on prevention of medical errors. The medical errors are introduced from various sources like medicines, surgery, diagnosis, equipment, lab reports etc. The best solution of the problem is to have comprehensive approach for different aspects of reporting of medical errors and related adverse episodes. The culture of reporting medical errors should be inculcated at all levels including hospitals, clinics, outpatient surgery centers, nursing homes, pharmacies and patients’ home. All the issues associated with reporting should be sorted out. The reporting of medical mistakes can provide invaluable advice to improve medical systems. Building a robust database error reporting system is the step towards delivering quality healthcare. Medical error reporting system should involve both adverse events and close calls nationwide. This will held healthcare providers responsible for any mishap leading to serious injury or even death of the patient. The reporting is automatically going to reduce negligent healthcare errors. This ultimately is going to reflect healthcare system to reach at the highest standard. NYPORTS system of New York delivers information to the state and hospital by identifying, analyzing medical errors and recommends strategies to ameliorate them. IOM has reported that the analysis of errors is very informative. The analysis of deadly mishaps which land up patients to bear life time fatal disabilities might be able to figure out the patterns of system flop. Methods of reporting systems IOM recommends two types of reporting systems: voluntary reporting system and mandatory reporting system. These systems will able to identify potential precursors to errors and it will eventually focus on identifying threats to safety of the patient. The data of the error records should be kept confidential to protect privacy of very individual involved in dealing with particular treatment from patient to healthcare providers. Healthcare providers should be encouraged by their organizations to report committed or observed medical errors during the course of the service to patients. Learning from the mistakes is the inherent part of reporting system. So from the next time care will be taken by the individual health service provider to avoid mishaps. Structured action plan for reported frequent preventable medical errors due to shear negligence is necessary to prevent them happening again in the future. Confidentiality in the medical reporting system encourages voluntary reporting of medical errors. Mandatory reporting system (QuIC, 2000) The state government should collect all the information of hazardous events related deaths or serious injuries from institutions, hospitals, clinics, ambulatory care delivery systems etc. This collection method should be enacted nationwide. The collected database should be made available to public to highlight medical errors. This strategy focuses on increased accountability of healthcare providers at the same time making public aware of the quality healthcare service. The mandatory reporting system certainly has to respect privacy of patient and healthcare professional. This system should also be implemented for blood banks and establishments that deal with blood products nationwide. These reports should cover errors due to mistyping blood products and adverse events affecting safety of donors and patients. The sole aim of the mandatory reporting system should be open access to information on medical errors so as to note them carefully and prevent the recurrence of these blunders in the future. Federal government, state government and other private-sector stake holders together can work for creating widespread medical error reporting system in the interest of safety of the patients. Federal agencies can play an important role in establishing and strengthening medical error report system which will able to deliver safety standards to patient. Following actions can be taken to enhance capability of mandatory reporting system: Recognize and develop basic standard measures for patients’ safety to facilitate uniform system of gathering factual information Adopting mandatory reporting system by all healthcare systems voluntarily Adopting penalty free confidential reporting systems initially to assist hospital to change their medical delivery systems on pilot basis Identifying and evaluating issues related to the implementation of medical error reporting system Deciding the effective way to expose the collected, validated data in front of public considering both positive and negative impact on them due to increased awareness of medical errors Evaluating the effectiveness of currently implemented mandatory reporting system at federal and state levels to map out better reporting system Voluntary reporting system (QuIC, 2000) This system has recognized restrictions for assaying the recurrence of medical errors (Flynn, Barker, Pepper, Bates, & Mikeal, 2002). The methods that detect the errors should enrich the reporting system. These methods should be used in all health care management settings. The complement methods are electronic prescription, use of bar coding system, computerized detection of adverse drug events, inspection of medication proceedings in hospitals to prevent administration errors, and audits of filled or computerized prescription in community pharmacies to examine dispensing mistakes. The various external agendas for patients and health care providers to report medical errors can assist to improve the reporting system (IOM, 2004). This is the sole system which can bring out positive change in the healthcare practitioners outside their organization, that too without getting mentally hurt and noticed by others. Doctors and nurses hesitate to disclose the medical errors that they have committed due to shame, guilt, and perfect performance expectation which is the demand of medical profession. Then the involved individual tries to hide the medical errors which affect the goal of the reporting system. All the staff associated with healthcare should be convinced that reporting errors is a part of improving healthcare system to detect system problems rather than blaming them. They should be ensured that they will not have to undergo legal proceedings after identifying their mistake. Reporting of all the medical errors will keep track of all the errors in the system and it will help to take proper measures to prohibit them. The concerned professional should be made aware of their responsible behavior to improve standards of healthcare management. Many times the poor performance of healthcare provider may not be the root cause of medical error. It might be due to system failure. Since voluntary reporting system dos not indicate the identity of healthcare provider, it will certainly provide a large database of incidents which occur due to medical errors. This will able to pinpoint frequent errors which can be prevented by proper intervention, guidance and recommendations. This learning through mistake strategy should be focused on underlying causes of adverse events or mishaps and is a positive way to prevent frequent medical errors by corrective measures taken by organization. These reporting systems are not obstacles to healthcare practitioners. It does not mean that healthcare providers’ illegal, negligent behavior is allowed. They are accountable of their malpractices or poor performance which risks the patient’s safety. Conclusion The culture of patients’ safety should be nurtured to respect the medical profession. Mandatory reporting system and voluntary reporting system should be properly amalgamated to make reporting system more efficient and effective. The resultant generated information should be able to design suitable patient safety programs. All the healthcare team members including the patient undergoing treatment should be active member to make healthcare system superior. References Flynn, E. A., Barker, K. N., Pepper G. A., Bates, D. W., & Mikeal, R. L. (2002) Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. American Journal of Health—System pharmacy, 59 (5), 436-446. The Quality Interagency Coordination Task Force (QuIC). (February 2000) Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Retrieved on Apr 19, 2008, from http://www.quic.gov/report/mederr2.htm Institute of Medicine (IOM). (2000). To Err Is Human: Building a safer healthcare system.Washington, DC: National Academy Press. Institute of Medicine (IOM). (2004). Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academy Press. Read More