Reporting on patient safety and medical errors

Reporting on patient safety and medical errors Richard Smith Editor, BMJ www.bmj.com/talks

What I want to talk about • A picture • A story • Why did we forget? • “The report” • The role of medical journals • The role of the mass media • The role of the web • The role of the WMA

A picture

A story

There’s nothing new about this • “First, do no harm”

Why then did we forget it? • We didn’t understand the extent of the harm • We were too busy concentrating on benefit • It’s painful to think about harm • “There but for the grace of God go I” • We thought about it in terms of culpability and didn’t know how to respond

“The report”: Institute of Medicine Report • To Err is Human: Building a Safer Health System • Put safety to the top of the US health agenda • Every country needs one

The role of medical journals

What journals can’t do • Make change happen straight away: “Words on paper don’t change things” • Tell people what to think

What journals can do • Disturb, stir up, encourage debate • Set agendas: “Tell people what to think about” • Legitimise: “If the NEJM is talking about safety it must be important”

The role of medical journals • Reporting scientific data • how many errors? • what type? • why do they happen? • what should be done about them? • Raising consciousness • Setting the agenda • Educating

Reporting error: USA • Harvard Medical Practice Study • Published in the New England Journal of Medicine in 1991 • In 3.7% of hospital admissions an adverse event led to harm

Reporting error: Australia • Australian study • Published in the Medical Journal of Australia in 1995 • An adverse event occurred in 16.6% of admissions

Not reporting error: UK • “If the [US] results apply in then about …45 000 may die in part because of the [adverse] event…Every country needs such a study…” • BMJ editorial, 1990

Setting the agendaRaising consciousnessEducating

How to reduce error • Quality improvement reports • Context • Problem • Measures of improvement • Information gathering • Strategy for change • Effects of change • Next steps

Journals specifically concerned with safety

The role of the mass media • Reporting cases to the world: the world is interested • Reporting data • Explaining error: Why does it happen? What can be done? • Generating political commitment for improvement

The role of the web • Enormous potential for sharing • High quality information • Tools • Experiences • Contacts • Many websites are appearing and will appear

Purpose of Qualityhealthcare.org • Help improve the quality of health care worldwide • Be easily accessible free or at very low cost • Provide trusted content and tools to improve healthcare • Put experts throughout the world in touch with one another

The role of the WMA • Raise consciousness • Convince member associations that they should be thinking about this issue and doing something • Put them in touch with people who can help them • Produce a grand statement that commits members to improving patient safety

Reporting on patient safety and medical errors

Reporting on patient safety and medical errors

Presentation Transcript

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Patient Safety: How You Can Prevent Medical Errors

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Quality Improvement and Reporting of Medical Errors

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Patient Safety Reporting System

Patient Safety Reporting System

Patient Safety Reporting System