Although differences did not achieve statistical significance, Dr. Chaudhry says the data were illuminating and the hospital administration was anxious to clarify the processes of care that could be modified to make the workflow more efficient and the different pieces of each patient’s critical data more integrated.
“For instance,” she says, “at our hospital there was a lot of separation of data. … The vitals were right outside the patient’s room. The list of medications was kept in a central pharmacy location, and the medical chart with everyone’s notes was in a third location.”
After the study’s completion, the integration of data was facilitated by the adoption of an electronic medical record (EMR) and there is ongoing research at that institution concerning whether that has affected error rates.
Hospitalists are ideally poised to take a lead in promoting patient safety by becoming more involved and developing the systems for error reporting.
—Sarwat Chaudhry, MD
“This was one of the first and, still I think, only studies of attending physicians reporting their own errors,” says Dr. Chaudhry, “as well as reporting the scope, type, and frequency of the errors.”
There were several lessons learned. The first is that near misses are very common—at least as common as adverse events and perhaps more frequent. The second is that the nature of near misses is similar enough to that of adverse events that they can still be informative in preventing harm to patients. The third lesson arises from the investigators’ review of the kinds of errors that were reported by the different providers. “Different types of providers are going to pick up on different kinds of errors,” says Dr. Chaudhry. “Pharmacy, of course, is going to be detecting drug errors. But nurses are going to be detecting a different kind of error than residents, and residents are detecting a different kind of error than attending physicians.”
Dr. Weingart, who was trained as an internist, says his sense is that “we often pick up errors that occur just upstream in the process of care. For instance, pharmacy finds doctor prescribing errors and nursing finds pharmacy dispensing errors.”
Drs. Chaudhry and Olofinboba discovered 17/47 (36%) of the errors on their own, and pharmacists, resident physicians, consulting physicians, nurses, and ancillary staff discovered the remaining 30/47 (64%). The hospitalists were more likely to detect therapeutic errors; house staff physicians were more likely to detect drug errors. House staff also detected procedural errors at a higher rate than did the hospitalists. Consequently, Dr. Chaudhry emphasizes, another highlight of these data shows that “engaging as many different kinds of healthcare providers in error reporting is very important to understand what’s going on.”
The two hospitalists in Dr. Chaudhry’s study underwent no formal training in error detection, and all errors identified were documented. This in itself is a remarkable aspect of this study for hospitalists to note.
“In most hospitals, the risk management department feels like breaking out a bottle of champagne to celebrate every time a physician submits an incident report,” says Dr. Weingart, “because in most hospitals physicians don’t view incident reporting as part of their responsibility. On the other hand, physicians constantly talk about the errors, near misses, and adverse events they encounter day-to-day. Unfortunately, formal incident reporting isn’t an activity that most physicians see as a part of their duty to deliver excellent care at the bedside.” By virtue of this, he says, “critical information is often lost to the system. Error experience is transmitted person-to-person but isn’t captured and analyzed.”