June 21, 2022 | Health System Risk Management
The universal prevalence of medical errors is a primary driver for effective event reporting. Citing estimates that as many as one in 10 patients is harmed while receiving hospital care in developed countries, the World Health Organization (WHO) has designated patient safety as a serious global public health issue. (WHO) Estimates are even higher for certain populations:
Even still, underreporting of adverse events by staff members remains a problem despite many imperatives to report, such as:
Patient Safety and Quality Improvement Act
Although a variety of stakeholders are prospective reporters, including physicians, nurses, pharmacists, support staff, patients, and families, there are notable differences in who actually reports, and at what frequency. Researchers have found that most reports are submitted by nursing staff, who believe that safety reporting is one of their job responsibilities; pharmacists are also frequent reporters for medication-related events. However, physicians and medical residents, who are in the position to have intimate knowledge of events and their sequelae, tend to be less familiar with what and how to report, and may believe that reporting is not part of their job; therefore, they typically contribute a very small fraction of reports. (Heavner and Siner; Mansfield et al.)
A study conducted by the U.S. Department of Health and Human Services' Office of Inspector General (OIG) revealed that in the absence of clear event reporting requirements, hospital staff neglected to report 86% of events to incident reporting systems, in part because of staff misperceptions about what constitutes harm. (OIG "Hospital") Other research also indicates that voluntary incident reporting systems capture only a small portion of patient safety incidents, and that underreporting occurs even with mandatory systems. (Mansfield...