Thursday, 3 August 2006
Hospitals will be safer if we learn from mistakes
The health system needs to learn from mistakes in order to make our hospitals a safer place, according to a paper in
this week’s New Zealand Medical Journal, published by the New Zealand Medical Association.
“Doctors need to feel comfortable reporting mistakes. When mistakes are investigated then the underlying system flaws
that allow them to occur can be identified and fixed, and this will improve the safety in our hospitals,” says NZMA
Chairman Dr Ross Boswell.
The paper, Learning from mistakes in New Zealand hospitals: what else do we need besides “no-fault”? showed that doctors
are very likely to report major mistakes. They are also very likely to report minor mistakes to patients, but rather
less likely to report them through hospital administrative systems.
The author, Farzad Soleimani from Stanford University, suggests that to learn from mistakes, we need to have a system
that not only facilitates the reporting of major errors but also encourages the reporting of minor ones.
The author suggests that it may be necessary to provide legal protection to prevent the media publication of errors in
order to decrease the barriers to reporting. For example, a recent law change in Florida for mandatory publication of
quality assurance data led to reduced reporting of errors, reducing the opportunities for learning from them.
“Finger pointing and blaming of individuals - the ‘name, shame and blame’ environment -- achieves very little in the way
of increased quality,” said Dr Boswell.
The NZMJ study was conducted to give a more in-depth understanding of some of the key factors influencing medical error
reporting behaviours of New Zealand doctors. It aims to offer some guidelines about creating an environment in which
learning from mistakes is carried out in a more open and effective manner.
“Doctors are human and we all sometimes make mistakes, just like everyone else. We need to ensure that our systems are
improved to catch mistakes before harm occurs, so that standards of care are improved,” said Dr Boswell.
ENDS