The study said poor error-reporting systems lead physicians to depend on discussions with colleagues rather than reporting to the hospital or health organization, and important information regarding medical errors and prevention is lost.
Between July 2003 and March 2004, AHRQ authors polled more than 1,000 physicians and surgeons practicing in rural and urban areas in Missouri and Washington State.
The results showed that 56 percent of physicians had prior involvement with a serious error, 74 percent were involved with a minor error and 66 percent reported a "near miss." More than half, 54 percent, agreed with the statement that "medical errors are usually caused by failures of care delivery systems, not failures of individuals."
According to the survey, few physicians believe they have access to a reporting system designed to improve patient safety, and 45 percent don't know if one exists at their organization. Only 30 percent of those surveyed agree that current systems to report patient safety events are adequate.
Physicians said that in order to formally report error information, the following would be needed:
- Information must be kept confidential and non-discoverable (88 percent);
- Evidence should be made available that such information would be used for system improvements (85 percent) and not for punitive action (84 percent);
- The error reporting process must take less than two minutes (66 percent); and
- The review activities must be confined to their department (53 percent).
“These findings shed light on an important question--how to create error-reporting programs that will encourage clinician participation," said AHRQ Director Carolyn M. Clancy, MD. “Physicians say they want to learn from errors that take place in their institution to improve patient safety. We need to build on that willingness with error-reporting programs that encourage their participation.”