Virtually all hospitals allow physicians and other health professionals to report adverse events, but a new study finds that most reporting systems fail to cultivate a so-called culture of safety that can help prevent future errors.
Less than a third of hospital reporting systems let doctors, nurses and others recount mistakes anonymously and promise privacy for those who identified themselves, said the survey of risk managers at 1,652 U.S. hospitals reported in the December 2008 Quality & Safety in Health Care. Only 13% of hospitals drew adverse-event reports from a wide variety of health staff. More than 80% of risk managers said they received few or no reports from physicians.
Just one in five hospitals issued adverse-event reports within two weeks of an incident. About the same number gave those reports to the key hospital departments and committees charged with protecting patients. One in three hospitals failed to disseminate analyses of the adverse events and near mistakes that were reported.
The whole shebang.