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Re-invent risk management by boosting near-miss reporting

Posted Jan 13 2011 10:31am

by Dev Raheja

Dev Raheja patient safety expertMuch evidence suggests that current risk management practices do little to increase patient safety. "Patient safety incidents show no decline," according to HealthGrades' evaluation of 2006-08 data.

What's more, over 52 percent of employees don't report any medical errors, according to data from the Agency for Healthcare Research and Quality.

Even when the incidents are reported, the results are not pretty. Physicians almost never report any incidents. In a review of 1,000 incident reports, nurses filed 89 percent of the reports, physicians only 2 percent. Nearly 60 percent of incidents were preventable.

The biggest risk, in my experience in risk management, comes from not reporting the "near-misses." Employees and physicians know about many more near-misses than they report. Worse yet, each of these events has the potential to harm patients.

Perhaps it's time to jettison conventional methods that have yielded poor results and consider more unconventional approaches to eliminating errors. Here is one worth your consideration that might help boost potential adverse event reporting.

To prod your employees to report near-misses, you can try creative approaches or a reward system. Here's an example: Ask the employees to report such errors and unsafe events (such as a ventilator failing to alert) and make sure they know you will protect their anonymity and their co-workers'. You will get hundreds of incident reports instantly.

That's been my experience and American Airlines'. The Federal Aviation Administration used to have 130 reasons for near-miss aircraft accidents in their database. But American Airlines thought more were possible, so it asked employees to report on any mistake anyone could make and promised not to name names. Since this survey was not punitive, the employees came up with about 12,000 potential ways.

Dev Raheja is president of Patient System Safety. This post was an excerpt adapted from his upcoming book, Safer Hospital Care, due out on Jan. 25.

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