People go to hospitals to be treated for an illness or for corrective surgery with the expectation they will return home in much better health than when they entered the medical facility. The reality, though, is that many may never recover or return home. A 2009 study by Hearst newspapers estimated the death toll from preventable medical mistakes is nearly 200,000 annually in the United States. That’s not much different than a 2004 report from HealthGrades, a healthcare quality organization, showing that in the three previous years, about 195,000 Americans died each year; the result of preventable medical practices in hospitals.
One way of lowering those numbers is to reform the way errors are reported, which in this country are often beset by complex and contentious procedures, according to the reports. Improvements in hospital safety practices begin with the reporting of errors and potential mistakes in the care of patients, said Dana E. Sims, who focused a study on the influence of a learning orientation culture within an organization and trust in leadership on workers’ willingness to formally report and document errors.
Sims, who conducted the study for doctoral dissertation at the University of Central Florida in 2009, presented her findings earlier this month at the Society for Industrial and Organizational Psychology’s annual conference in Atlanta.
There is no uniform reporting among states in regard to releasing information about mistakes. In March the Inspector General of the Department of Health and Human Services issued a report that indicated hospitals are not consistent in gathering information about preventable medical errors because of inadequate hospital data and poor internal tracking of medical errors by hospitals themselves.
Accurate reporting of errors depends upon whether organizations encourage, support and follow up the documentation of errors and practices that can harm patients. Also, compiling information relies heavily on front-line employees, nurses and medical staff, being able to report mistakes within a non-threatening culture.
“It’s important to identify and adapt procedures that are unsafe and potentially can lead to serious mistakes,” said Sims. “If hospital administrators are unaware of mistakes and unsafe practices, they cannot do anything about them.”
Too often healthcare workers believe error reporting is a sure path to trouble that will result in blame and punishment to those involved. On the other hand, some hospitals will avoid finger-pointing and instead take a holistic view of where the systemic failure may have occurred, said Sims.
Her study of care units within two hospitals found that organizations and leaders who promote a “learn from our mistakes” culture may bolster employees’ decisions to openly discuss errors.
“A smart organization knows that employees are aware of practices and incidents on the front-line that the administration does not want to hear. But the administration needs to encourage employees to report them anyway to avert disaster,” Sims said. Sometimes top leaders are too insulated from what is happening within the organization, she added.
“In the long term, hearing what employees have to say can save lives as well as prevent expensive lawsuits and damages to a hospital’s reputation,” she said.
She found that perceptions about the organization are the strongest predictor of whether employees’ tend to document errors.
