Survey reveals reasons doctors avoid online error-reporting tools

"Too busy," and "too complicated." These are the typical excuses one might expect when medical professionals are asked why they fail to use online error-reporting systems designed to improve patient safety and the quality of care. But, Johns Hopkins investigators found instead that the most common reason among radiation oncologists was fear of getting into trouble and embarrassment.

Investigators e-mailed an to physicians, nurses, radiation physicists and other radiation specialists at Johns Hopkins, North Shore- Long Island Jewish in New York, Washington University in St. Louis, Missouri, and the University of Miami, with questions about their reporting near-misses and errors in delivering radiotherapy. Each of the four centers tracks near-misses and errors through online, intradepartmental systems. Some 274 providers returned completed surveys.

According to the survey, few nurses and physicians reported routinely submitting online reports, in contrast to physicists, dosimetrists and radiation therapists who reported the most use of error and near-miss reporting systems. Nearly all respondents agreed that error reporting is their responsibility. Getting colleagues into trouble, liability and embarrassment in front of colleagues were reported most often by physicians and residents.

More than 90 percent of respondents had observed near-misses or errors in their clinical practice. The vast majority of these were reported as near-misses as opposed to errors, and, as a result, no providers reported patient harm. Hospitals have specific systems for reporting errors, but few have systems to accommodate the complex data associated with radiotherapy.

"It is important to understand the specific reasons why fewer physicians participate in these reporting systems so that hospitals can work to close this gap. Reporting is not an end in itself. It helps identify potential hazards, and each member of the health care team brings a perspective that can help make patients safer," says Johns Hopkins radiation oncology resident Kendra Harris, M.D., who presented an abstract of the data on October 2, 2011, at the 53rd Annual Meeting of the American Society for Radiation Oncology (ASTRO).

The good news, Harris says, is that few respondents reported being too busy to report or that the online tool was too complicated. "Respondents recognized that error events should be reported and that they should claim responsibility for them. The barriers we identified are not insurmountable," she added.

Harris says that online reporting systems should be simple and promoted as quality improvement tools, not instruments for placing blame and meting out sanctions. "These systems should not be viewed as punitive; rather, they're a critical way to improve therapy," says Harris. "You can't manage what you can't measure."

Most of the respondents said they would participate in a national reporting system for radiotherapy near-misses and errors.

"A national system that collects pooled data about near-misses and errors, which are thankfully rare, may help us identify common trends and implement safety interventions to improve care," adds Harris.

Provided by Johns Hopkins Medical Institutions

5 /5 (1 vote)
add to favorites email to friend print save as pdf

Related Stories

Computerized systems reduce psychiatric drug errors

Mar 21, 2011

Coupling an electronic prescription drug ordering system with a computerized method for reporting adverse events can dramatically reduce the number of medication errors in a hospital's psychiatric unit, suggests new Johns ...

Preventing physician medication mix-ups by reporting them

Dec 03, 2010

The most frequent contributors to medication errors and adverse drug events in busy primary care practice offices are communication problems and lack of knowledge, according to a study of a prototype web-based medication ...

Teaching future doctors the basics of medication errors

Jan 19, 2011

Medical students should have basic knowledge of common medication errors before they begin seeing patients at the hospital, and researchers from the Johns Hopkins Children's Center report that allowing them to play detective ...

Recommended for you

What are the chances that your dad isn't your dad?

5 hours ago

How confident are you that the man you call dad is really your biological father? If you believe some of the most commonly-quoted figures, you could be forgiven for not being very confident at all. But how ...

New technology that is revealing the science of chewing

Apr 15, 2014

CSIRO's 3D mastication modelling, demonstrated for the first time in Melbourne today, is starting to provide researchers with new understanding of how to reduce salt, sugar and fat in food products, as well ...

After skin cancer, removable model replaces real ear

Apr 11, 2014

(HealthDay)—During his 10-year struggle with basal cell carcinoma, Henry Fiorentini emerged minus his right ear, and minus the hearing that goes with it. The good news: Today, the 56-year-old IT programmer ...

Italy scraps ban on donor-assisted reproduction

Apr 09, 2014

Italy's Constitutional Court on Wednesday struck down a Catholic Church-backed ban against assisted reproduction with sperm or egg donors that has forced thousands of sterile couples to seek help abroad.

User comments