This paper describes a simple and inexpensive method to identify quality problems and sources of iatrogenic injury among hospitalized patients. The method integrates confidential peer interviews of house officers into the workday. Employing this approach, the investigators identified an AE in 2.6% of medical admissions. Recognizing that the study definition of AEs may make direct comparisons difficult, the prevalence of AEs is similar in magnitude to previous work: 2.8% in O'Neil's study of house officer self-reporting14
and 3.7% in the MPS.1
An AE, PAE, or other house officer-identified quality problem occurred in 10% of admissions. Many events were preventable. A large number involved interpersonal conflict among front-line caregivers.
Although a majority of house officer-reported events were corroborated in the medical record (73%), only one such event was recorded in the hospital incident reporting system. Conversely, house officers failed to report 57 of 58 events recorded in the incident reporting system. In practice, nurses recorded the overwhelming majority of incident reports; it is possible that house officers perceive incident reports as a nursing responsibility. House officers may be unaware of slips and falls without injury, drug-dose discrepancies, or other events that do not require their intervention. As a result, incident reports and the confidential clinician-reported surveillance method described here are complementary approaches for detecting AEs and iatrogenic injury.
There are several reasons why the results must be interpreted cautiously. First, events are based on the report of individual clinicians. Although medical record review corroborated a substantial number of reports, prospective corroboration with the patient or other providers would enhance a report's validity. Second, clinicians' reports offer limited information about the systems problems that account for most medical errors. The study identified a series of process problems, but did not examine the ultimate or “root” causes that led to the event. Third, assessment of preventability may be subject to bias. Knowledge of adverse outcomes may cause reviewers to judge quality more harshly.16
Event narratives often contained information about adverse consequences, so investigators were not blinded to outcome. The fact more preventable events occurred among PAEs than AEs suggests that hindsight bias played a relatively small role.
Fourth, the adverse event rate is almost certainly an underestimate. House officers may fail to report events because of their own perceived vulnerability to supervisors' approbation, fear of developing a bad reputation, or a sense of powerlessness. A culture of fear in health care holds perfect performance as an ideal and imposes blame and shame for those who fail to meet the mark.17
Many take error for granted as a necessary part of the learning process, or as a necessary consequence of the complexity, toxicity, or heroics of modern medical care. They may be unaware of events that occur on evenings or weekends, when another house officer provides cross-coverage. They also may be ignorant of events that are intercepted by a nurse or pharmacist and never communicated verbally or in the medical record. House officers' reports may be enriched in events that were most recent, most annoying, or reflect selective attention to a controversial service area. The sample includes events that clinicians found vexing, and which they may feel motivated to address.
Fifth, the generalizability of the approach requires further study. The interviewer was a general medicine fellow who knew most respondents well and was likely viewed as a peer. Respondents may be more likely to report mistakes to a trusted peer than to a supervisor or stranger. The approach needs to be tested with nurses and other front-line clinicians. Attending physicians may be less willing to participate because of their concerns regarding liability exposure and uncertainty about the durability and scope of peer review protections. Finally, the culture of the academic medical center under study may have offered a non-punitive environment that was conducive to self-disclosure.
Despite these caveats, the approach presented here has many attractive features. It is timely, inexpensive, and acceptable to clinicians. It identified more events and more serious events than those recorded in the hospital incident reporting system. Its face-to-face peer interviews yielded more reports than e-mail prompts, and may be adapted to a variety of settings. The authors used a similar approach with house officer respondents in the medical intensive care, oncology, and cardiac step-down units, and in an outpatient primary care practice. They also collected reports from nurse-respondents on inpatient general surgery and oncology units. In each setting, clinician interviewers were known to respondents and held informal interviews in staff meetings, work rounds, and other settings that were part of the regular workday.
While the model is replicable in a single hospital, it has not yet been implemented as an ongoing quality improvement activity. To create a sustainable model, participation should become part of a hospital quality improvement strategy with data collection and analysis assigned to a chief resident or other responsible staff physician. It must become integrated into the daily rhythm of the work and viewed as complementary to, rather than a distraction from, the mission of patient care. Creating a mechanism to act on clinicians' reports will enhance the credibility of the effort and reinforce respondents' willingness to participate. We recognize that organizations must take available resources into consideration and recommend that they solicit the views of house officers about potential interviewers.