Estimates vary, but preventable U.S. hospital deaths annually have run in the tens of thousands in recent years.
The movie industry and media have brought some medical mistakes and tragedies to light. The streaming television series Dr. Death is based on the gross malpractice by a former American neurosurgeon who was sentenced to life imprisonment. The documentary To Err is Human explored worst-case scenarios of medical errors and the culture that continues the problem.
Heidi Raines, author of Shared Voices: A Framework for Patient and Employee Safety in Healthcare, says some hospital deaths and patient injuries could be prevented with better reporting by healthcare workers about patient safety issues.
“By increasing the reporting of near misses and unsafe conditions, healthcare organizations gain a greater understanding of their safety challenges and prevent future harm,” she says.
About 86 percent of patient safety incidents occurring in healthcare organizations go unreported, according to a study released by the U.S. Department of Health and Human Services.
“Barriers to reporting, such as fear of blame or retaliation, lack of understanding about what qualifies as a safety event or near miss, and the complexity of the reporting process can all deter reporting,” she says. “But for patients to receive the highest quality of care possible, reporting must become a proactive undertaking, rather than one that collects or performs analysis only after harm occurs.”
Raines offers these tips for how healthcare organizations can encourage their staffs to report incidents and what can be learned in the process.
- Emphasize anonymous reporting. Raines says that with many patient safety events going unreported due to fear of blame or retaliation, anonymous reporting can help organizations place the focus back on patient safety and shift from a culture of blame to one of encouragement. “That would become a culture that identifies systemic and root causes, learns from reports, and takes targeted actions to prevent future occurrences,” she says. “Anonymous reporting can increase the number of reports submitted by decreasing the fear of negative repercussions and other incentives to hide information.”
- Lower the reporting threshold. “The great value of reporting near misses and all incidents is not just that they provide organizations with a more complete picture of what risks may exist, but also that they encourage even more reporting among staff,” Raines says. “Within a culture of safety, reporting is destigmatized.”
- Clarify that all relevant factors will be analyzed. When staff members are convinced that near misses and incidents are the product of multiple factors and that all contributing factors will be considered during analysis, Raines says, “they will understand patient safety to be the responsibility of entire care systems rather than individuals.”
- Conduct logical analyses aimed at action plans. Employees will have a greater trust in the process if there is a thorough review of all contributing factors and underlying causes, such as understaffing, poor system design, and faulty equipment, Raines says. When action plans address relevant issues, “an organization demonstrates its commitment to long-term results rather than short-term fixes,” she says.
- Share the results of the process. “Key action points should be shared with clinical staff,” Raines says, “and regular training should emphasize a team-based approach by outlining some incidents and discussing both their causes and changes made to prevent the recurrence. Reporting succeeds when results are communicated through system improvements.”
“Many of us in healthcare entered the profession because we wanted to help, heal, and serve,” Raines says. “”At our core, we have compassion, empathy, and a drive to help people live their best lives.
“Recognizing and implementing actions to prevent patient and employee harm has the greatest potential effect on the quality of care delivered in our healthcare system, just as preventative care and wellness efforts slow or stop the progression of disease.”
About Heidi Raines
Heidi Raines is the Forbes Books author of Shared Voices: A Framework for Patient and Employee Safety in Healthcare. She also is the founder and CEO of Performance Health Partners (www.performancehealthus.com), a software company providing patient safety, employee health and quality improvement solutions to healthcare organizations. In addition, Raines is the Board President of the American College of Healthcare Executives’ Women Healthcare Executive Network and holds Preceptor Faculty positions at Tulane University’s Master of Health Administration (MHA) and University of New Orleans’s Bachelor of Healthcare Administration program. Raines has received awards for innovation and executive leadership, including City Business’ Innovator of the Year and Woman of the Year awards.