Medical Mistakes Are 'Leading Cause' of Death and Disability
Because the fear of litigation or other repercussions impedes an open discussion, the report calls for minor errors to be treated in confidence. "If errors cause no harm or little harm, the information about these errors should be protected [so that we can put] corrections into the system. On the other hand, serious errors need to be reported externally so we can learn," Kohn says. "The committee distinguished between these two types of errors.
"Health care organizations need to make patient safety a priority and devote resources to designing safer systems. Medical errors ... can occur in all issues related to the process of providing care. We know the system can be designed to improve safety, because several industries have better safety records," Kohn says.
Examples of systems errors include the classic, poor handwriting on paper prescriptions. If physicians in a health care system type prescriptions onto an electronic template, the risk of penmanship-related problems is eliminated. While individual physicians and pharmacists have little recourse other than being more careful about drugs with similar names, the FDA can monitor these names and call attention to the possibility of confusing them, Kohn tells WebMD.
Another example she cites is the rapid growth in medical knowledge, which makes keeping abreast difficult for health care workers. "Access to information, at the right place and at the right time, can help improve safety," she says.
Mainstream media analyses have been skeptical about organized medicine's concern about patient safety, which they view as belated. For example, in the New York Times, Lawrence K. Altman questions "why, after so many years of public attention to medical malpractice, the National Academy of Sciences wants to crack down now."
Systemically based errors can be reduced without making health care professionals even more vulnerable to lawsuits, and without reinventing the wheel, Wade tells WebMD. "[O]ur systems for preventing [errors] are not what the public would expect of us," he says. "We need a reporting mechanism that will [allow information to be used] for all the right reasons and not used for all the wrong reasons. ... We can improve our systems by finding the places where medical error prevention is being done well and translating that information across the system. This approach will help us develop a system of safeguards that improve patient safety."