Feature Story

Physicians want to learn from medical mistakes but say current error-reporting systems are inadequate

The perception that U.S. doctors are unwilling to report medical errors and learn how to prevent them is untrue, according to a new study funded by the Agency for Healthcare Research and Quality (HS11890 and HS14020). Because most doctors think that current systems to report and share information about errors are inadequate, they rely instead on informal discussions with their colleagues. Consequently, important information about medical errors and how to prevent them often is not shared with the hospital or the health care organization. As a result, such information is not aggregated for analysis and systematic improvement.

To assess physicians' attitudes about communicating errors with their colleagues and health care organizations, the study authors used a 68-question survey to poll a geographically diverse group of more than 1,000 physicians and surgeons currently practicing in rural and urban areas in Missouri and Washington State. The survey was conducted between July 2003 and March 2004.

Most physicians reported that they had been involved in an error (Figure 1).

Figure 1. Percent of physicians reporting a medical error by error type

Almost all (95 percent) physicians agreed that they needed to know about errors in their organization to improve patient safety, and 89 percent agreed that they should discuss errors with their colleagues.

The majority of physicians (83 percent) said they had used at least one formal reporting mechanism, most commonly reporting an error to risk management (68 percent) or completing an incident report (60 percent).

Over half of physicians (61 percent) had used at least one informal mechanism to report an error to their hospital or health care organization, most commonly telling a supervisor or manager (40 percent) or physician chief or departmental chairman (38 percent). Physicians were more likely to discuss serious errors, minor errors, and near misses with their colleagues than to report them to a risk management or to a patient safety official.

Few physicians believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45 percent) did not know if one existed at their organization. Only 30 percent agreed that current systems to report patient safety events were adequate.

When asked what would increase their willingness to formally report error information, physicians said they wanted:

• Information to be kept confidential and non-discoverable (88 percent).
• Evidence that such information would be used for system improvements (85 percent) and not for punitive action (84 percent).
• The error-reporting process to take less than 2 minutes (66 percent).
• The review activities to be confined to their department (53 percent).

Percent of physicians reporting a medical error by error type:

• 56 percent: Serious error
• 74 percent: Minor error
• 66 percent: Near miss

See "Lost opportunities: How physicians communicate about medical errors," by Jane Garbutt, Amy D. Waterman, Julie M. Kapp, and others, in the January/February 2008 Health Affairs 27(1), pp. 246-255.

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