Identifying Barriers to the Success of a Reporting System

Review
In: Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.

Excerpt

Spurred by a controversial report from the Institute of Medicine on the prevalence of medical error, To Err Is Human, the medical profession has seen an increase in event reporting systems at the international, national, and institutional levels. Aviation, with its long history of reporting systems, has shown that these systems can yield previously unknown, but safety-critical information for developing a proactive approach to managing human error. Despite many similarities between health care and aviation, event reporting systems have not been well received in health care. Studies have shown that many physicians are reluctant to participate in programs to report medical errors, and that underreporting of adverse events may be as high as 96 percent. These findings suggest that the success of a reporting system is determined by the attitudes and perceptions of frontline care providers. Therefore, prior to implementing an event reporting system, an assessment of the opinions of care providers should be conducted to identify critical barriers to reporting. The University of Texas Human Factors Research Project has developed a survey instrument designed to assess a wide array of attitudes deemed relevant to the implementation of reporting systems. This paper summarizes preliminary survey findings and recommendations for successful implementation of an event reporting system.

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