WASHINGTON—A study published in the April issue of Health Affairs found that medical errors cost the United States more than $17 billion a year. And, according to the Agency for Healthcare Research and Quality, medical errors and near miss events, i.e. any process or error that could have resulted in harm if it had not been caught, are responsible for injury to as many as one out of every 25 hospital patients.
Medical errors are not limited to civilian facilities, however, and the Military Health Service (MHS) is working toward making its hospitals safer for patients with the introduction of a new way to report patient-safety events.
To help learn from and prevent patient-safety events, the MHS is implementing a comprehensive web-based, anonymous reporting system at all of its MTFs. In the past, while some types of events could be reported electronically at MTFs, paper-based reporting of patient-safety events has been the norm.
“We have had pieces of it in the past,” explained Michael Datena, MPH, RPh, program analyst with the Patient Safety Program and the functional proponent for the Patient Safety Reporting System (PSR).
“For instance, for the medication piece, we have had an electronic system, but we have never had a system that collected all of the events—the medication events and the non-medication events. So, this is a first for us where we can collect everything in one place using a standard taxonomy.”
Without a standardized systemic collection of patient-safety event reports, it has been difficult for MHS to track system-wide trends and to analyze actionable information from these occurrences. By having this information, it is hoped that facilities can more proactively address patient safety issues.
“Our goal is to establish a culture of safety and quality in the MHS,” said Datena. “We were directed under the NDAA 2001 authorization to establish a patient care error reporting and management system and then study those errors and identify any systemic factors that might be there and then provide corrective action.”
Keeping Patients Safe
PSR currently is in about 51% of direct-care MHS treatment facilities and is expected to be fully deployed in the remaining MTFs for the end of June.
Anyone in an MTF with a Common Access Card can report in the system and has the option of remaining anonymous. Any identifiers would only be visible at the facility level where reported and not at higher levels.
Anonymous reporting is an important feature that encourages the sharing of information, Datena said. “The goal was to get people to report,” he said. “A lot of times people are hesitant to report because reporting in the past has had a punitive connotation. So, our goal is to really look at systems and processes and not assign blame. To do that, it works better if you can have an anonymous reporting system.”
Near-Miss Events Also Can Be Reported
Individuals can report not only adverse and sentinel events, but also near-miss events. MTF officials will have the capability of generating reports on their patient safety data, looking for trends at their facility and developing action plans and mitigation strategies. At higher levels, officials will have the ability to look across the MHS to identify trends and feed that information back to the facilities to help reduce events, Datena explained.
Datena said that the system is easy to use and should only take medical personnel a few minutes to input information. After an event is submitted into the system, the event is reviewed and causal factors are sought out for the event. “That is really the why and is really where you get most of your benefit from a system like this is people sit down and they think, ‘why did this happen?’” he said. “Once you get the why, then you can develop your mitigation strategy.”
The event is then reported at a higher level so service and systemwide data can be collected. In addition to improving care, the goal is to save expenses by reducing or eliminating medical errors.
Most Common Errors
The recent study, by Van de Bos et. al., used mathematical models based on claims data to estimate that the annual cost of measurable medical errors that harm patients was $17.1 billion in 2008. The most common measurable medical error was found to be pressure ulcers, followed by postoperative infections and postlaminectomy syndrome after back surgery.
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