“To Err is Human”: Uniformly Reporting Medical Errors and Near Misses, a Naïve, Costly, and Misdirected Goal

Abstract

Three years ago, the Institute of Medicine (IOM) in To Err Is Human—Building a Safer Health System reported an estimate of 44,000 to 98,000 annual deaths directly attributable to preventable medical errors. In subsequent conferences, discussions, and scientific articles, the media, the medical profession, national health care organizations, and Congress have scrutinized this staggering figure. Individual hospital risk management programs, medical error reporting systems, and national patient safety oversight projects have been created to systematize purportedly anonymous, nonpunitive methods that encourage universal reporting of medical errors and “near-misses.” Using the 26-year-old Aviation Safety Reporting System (ASRS), the National Aeronautics and Space Administration (NASA)-directed reporting system for the Federal Aviation Administration (FAA) as the “gold standard,” such methodologies have operated on the assumption that if a system claims to be anonymous, nondiscoverable, nonpunitive, and in the best interests of the patient, health care personnel will willingly report. Unfortunately, as Dr James Bagian, former astronaut and now director of the National Center for Patient Safety, Veterans Health Administration (VHA), eloquently stated recently before the joint annual meeting of the Association of Program Directors in Surgery and the Association for Surgical Education, the ASRS works not only because it is voluntary, nondiscoverable, anonymous, and nonpunitive, but also because the pilot is always the first to the crash site. In any medical error reporting system, it is usually the individual patient who is physically at risk, not the medical personnel. Yet our nation’s hospitals, medical systems, and governmental organizations have invested much time, money, and effort in establishing such error-reporting systems modeled after the ASRS in which the primary incentive to report—the preservation of one’s own life (as opposed to one’s own livelihood)—is missing. To one degree or another, existing error-reporting systems have tried to incorporate three principles thought to be basic to any system: it should be anonymous, nondiscoverable, and nonpunitive. But, for any program to be successful it must include a fourth principle: a guarantee of immunity for those who commit errors and those who report them. In our litigious society, any reporting system we create is bound to be besieged by lawyers and the press. There will be a natural reluctance to report errors. Yet, if we are going to create a system that is of any help at all in improving patient care, it must be as thorough and honest as we can make it. The history of error-reporting systems makes it clear that any system than ignores immunity cannot operate effectively, especially on a voluntary basis. On December 7, 1999, in response to the report by the Institute of Medicine, the Quality Interagency Coordination Task Force (QuIC), a presidential commission established to implement quality improvement initiatives, was directed by President Clinton to report to the Administration recommendations on how to improve health care outcomes and prevent medical errors. Outlined in The White House press release of February 22, 2000, the QuIC endorsed virtually every IOM recommendation and called for implementation of patient safety programs throughout the federal government, but especially the Departments of Veterans Affairs and Defense. Perhaps the best example of the development of well-intentioned quality assurance and error-reporting systems in patient care in the United States has occurred within the Department of Veterans Affairs (VA). The No competing interests declared.