Imaging Technology News | June 2012

Better systems that improve quality, learning and safety are the key to real improvements

By Teri Yates

Most experts embrace the notion that the best way to prevent medical errors is to learn from them rather than punish the individuals involved. Despite this, the facts suggest there is still much work to be done in establishing a just culture in healthcare that acknowledges the inherent likelihood that humans will make mistakes. The Agency for Healthcare Research and Quality (AHRQ) has studied this particular issue for years, and its most recent findings point to the fact that the majority of physicians still feel their organizations employ a blame-oriented rather than solutions-oriented approach to error prevention. In AHRQ’s “Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report,” more than 500,000 staffers representing 1,128 hospitals were surveyed.1 The majority of respondents, including physicians, feel that their mistakes are held against them.

This is particularly interesting when considered against the backdrop of the recent Office of the Inspector General (OIG) report entitled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.” In it, the OIG concluded that based on its study of claims from 2008, 86 percent of incidents that harmed Medicare beneficiaries were not reported to the hospital’s incident reporting system.2 The report opined on a variety of potential causal factors for this, including: