Legislation a powerful tool to change culture
If a devastating medical error occurred at your organization, would all the involved parties feel free to discuss the circumstances candidly and openly? Too often, the answer is no, and with good reason, says Jeffrey Driver, chief risk officer and director of the risk management department at Stanford (CA) Hospital & Clinics and presi-dent of the American Society for Healthcare Risk Management.
"The bottom line is — practitioners are not comfortable disclosing anything. They live in this world of fear," he adds.
After one prominent surgeon disclosed a medical error to the state, the matter quickly turned into a "shame-and-blame game" during the ensuing investigation, Driver recalls. "The physician said to me, and I will never forget it, I will never report another error to you.’"
Even with heightened awareness about the importance of nonpunitive reporting of medical errors, retribution still is common, he says. "In many cases, nurses are attacked by the state when they report errors; and even now, we still have hospitals with very punitive approaches to medical errors," he says. "This discourages disclosure and makes people just want to hide things."
If enacted into law, the Patient Safety and Quality Improvement Act, recently passed by the Senate, would allow health care errors and serious events to be reported in a voluntary and confidential manner, without the threat of legal repercussions. "This legislation is huge — it creates a national safe space for us to explore medical error and do something about it," Driver says. The House of Representatives passed a similar bill in 2003.
The legislation would establish a system for reporting and analyzing health care errors and adverse events in an environment that is free from blame, allowing individuals to explore why errors occurred and how to prevent them from occurring again, he notes.
Most states have peer review laws that protect communications of physicians but often do not provide for the same protection for other individuals such as nurses or quality professionals.
"The problem is that we are relying on state confidentiality and peer review laws to help each hospital and group of physicians to look at how quality can be improved, but it’s done in an environment of fear," Driver says. "You’ve got all this variability between the states, and some have very little protection."
The law would allow for medical errors to be reported to a single national database with complete confidentiality instead of the patchwork of databases that currently exists, such as Joint Commission on Accreditation of Healthcare Organizations’ Sentinel Event reports, state health departments, the Institute for Safe Medical Practices, and other private initiatives, he adds.
"This will reduces barriers to reporting, so we will have a very rich database. Then experts can make sense of the data and turn them into information that we can all use," Driver points out.
[For more information on the patient safety legislation, contact:
• Jeffrey Driver, Chief Risk Officer/Director, Risk Management, Risk Management Department, Stanford Hospital & Clinics, 300 Pasteur Drive, Room N021, MC: 5716, Stanford, CA 94305-5716. Phone: (650) 723-6824. Fax: (650) 736-2495. E-mail: JDriver@stanfordmed.org.]