Reducing mishaps from medical management is central to efforts to improve quality and lower costs in health care. Nearly 100000 patients are estimated to die preventable deaths annually in hospitals in the United States, with many more incurring injuries at an annual cost of $9 billion. Underreporting of adverse events is estimated to range from 50%–96% annually.1–3 This annual toll exceeds the combined number of deaths and injuries from motor and air crashes, suicides, falls, poisonings, and drownings.4 Many stakeholders in health care have begun to work together to resolve the moral, scientific, legal, and practical dilemmas of medical mishaps. To achieve this goal, an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care.
Outcomes in complex work depend on the integration of individual, team, technical, and organisational factors.5,6 A continuum of cascade effects exists from apparently trivial incidents to near misses and full blown adverse events.7,8 Consequently, the same patterns of causes of failure and their relations precede both adverse events and near misses. Only the presence or absence of recovery mechanisms determines the actual outcome.9 The National Research Council defines a safety “incident” as an event that, under slightly different circumstances, could have been an accident.10 Focusing on data for near misses may add noticeably more value to quality improvement than a sole focus on adverse events.
Schemes for reporting near misses, “close calls,” or sentinel (“warning”) eventshave been institutionalised in aviation,w1w2 nuclear power technology,w3w4 petrochemical processing, steelw5 production,w6 military operations, and air transportation.w7-w11 In health care, efforts are now being made to create incident reporting systems for medical near misses8,11–15 to supplement the limited data available from mandatory reporting systems focused on preventable deaths and serious injuries.
There are, however, powerful disincentives to reporting.16–18 Management attitudes and institutional climate can greatly influence the success or failure of reporting efforts.19 Reason identifies four critical elements of an effective safety culture—that is, a reporting, just, flexible, and learning culture.20 Can this model be validated in health care? Given the lack of a review that addresses these questions, we report our preliminary findings of a study of incident reporting systems for near misses in non-medical domains.
- Research studies have validated an epidemic of grossly underreported, preventable injuries due to medical management
- Recent policy documents have placed high priority on improving incident reporting as the first step in addressing patient injuries, and have called for translation of lessons from other industries
- Complex non-medical industries have evolved incident reporting systems that focus on near misses, provide incentives for voluntary reporting, ensure confidentiality while bolstering accountability, and emphasise perspectives of systems in data collection, analysis, and improvement
- Reporting of near misses offers numerous benefits over adverse events: greater frequency allowing quantitative analysis; fewer barriers to data collection; limited liability; and recovery patterns that can be captured, studied, and used for improvement
- Education and engagement of all stakeholders of health care and negotiation of their conflicting goals will be necessary to change the balance of barrier incentives in favour of implementing reporting systems