The pressure to reduce adverse events in hospitals has motivated health IT startups to develop a myriad of solutions from the pilot’s checklist to innovative communication devices that reduce the impact of shift changes and workflow interruptions on patients. It may be an excellent start, but it only takes care of the low-hanging fruit. In order to create substantive changes to increase reported medical errors, there needs to be some acknowledgement of a sad truth: People make mistakes.
It’s not exactly what you’d expect to hear from a doctor. Danielle Ofri, who is also an author in addition to her position at Bellevue Hospital Center at New York University, told an audience at TEDMED 2014 in Washington, D.C., that a frank conversation about the complex range of emotions attached to medical errors and a more transparent system to report them are essential to improving the problem.
The current culture has created a dangerous atmosphere in which doctors would rather hide medical errors than report them and face repercussions. Ofri admitted that she once declined to report an error she made while she was training to be a physician, and it’s haunted her.
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“Tending to an emotional landscape may seem too squishy, but despite our best efforts, there is no way to improve without acknowledgement of our imperfections,” Ofri said. “We need to undo a toxic culture of perfection when it comes to medical error.”
Easier said than done. Ofri acknowledged as much when she touched on the overriding fear of malpractice suits that punish doctors who admit errors.
Some states have tried to address patient safety concerns by sharing best practice guidelines to reduce adverse events, such as falls and medication errors. Pennsylvania, for example, has a Patient Safety Authority that collects information on medical errors from participating hospitals in the state.
Several states have passed legislation that allows doctors to express sympathy to patients and their families for poor outcomes, but without admitting guilt. States have been reluctant to pass these laws because of fears that it could lead to lawsuits.
