Can Error Reports Help Our Patients?

Robust error reporting has done wonders for the health industry. We no longer need to guess when a problem could occur. Most clinical staff carry a mental list of critical safety moments: From falls to blood transfusions, we know exactly where, when, and how our patients are under the highest risk of harm.

So what now?

One would think that this precision data would impact patient safety positively, but in our present decade, we find the opposite to be true: The Joint Commission issued a report showing that sentinel events (the ones that cause deadly harm) increased by 19% from 2020 to 2022 — that’s even worse than during the pandemic.[1]

The question remains: Do error reports help our patients?

Every quality method, and even the scientific method itself, has a period of data collection in the cycle of improvement. The reason we collect new data is to measure a change. Since our results have not changed in decades, I question the need for new data if we are going to wave the white flag and quit trying to improve care.

We need a new approach — a reason to measure and collect data again. That’s why I’m recommending a Recognize and Recover approach to patient safety reporting. Because somewhere along the way, it seems that we lost sight of the patients we were trying to help.

In the Advanced Cardiac Life Support (ACLS) protocol, the clinician recognizes the problem, prioritizes emergency treatment (the ABCs of Airway, Breathing, and Circulation), and then reviews a mental checklist of common causes for the problem so they can address the root cause of the event and prevent a repeat episode.

What if we focused on helping patients again? What if we focused on recognizing the problem and recovering the patient rather than hyper-vigilance on paperwork that tells us what we already know?

Among the case reviews I have studied, it seems like the worst cases of harm are caused by repeated delays, often by clinicians who are afraid to speak up, allowing the problem to multiply over hours and days. This is why early recognition matters: The difference between a smart catch and a sentinel event is whether staff recognized the problem and intervened.

In the court case of RaDonda Vaught,[2] who was charged criminally for a medication error, it was not the error type that turned the case, but the lack of monitoring (recognition) after administering a high-risk medication that could require intervention. It seems logical, then, that we would reward nurses for sharing victories in patient monitoring and intervention, but unfortunately, we only ask them to tell us about the times they failed.

In many ways, the obsession with error reporting is working like a gag in the mouths of clinicians who spend their time debating what it will cost them to report rather than focusing on what the patient needs right now. But if we recognize errors early on and treat them quickly, I believe patients are far less likely to deteriorate into sentinel events. Silence is deadly.

The spidey-sense of a clinician is still the best alarm system in the world. We should not allow alarm fatigue to silence our best clinicians because our reporting parameters are skewed.

We can begin by reporting our rescue efforts instead of fixating on our mistakes. And when patients take priority in our patient safety culture, perhaps it will be worth our time to collect data again.

Right now, we only ask what went wrong. We should be asking, “What could have happened if you had not acted? What could help us respond more quickly and effectively next time?”

I can safely say that clinical staff are much more likely to write a report that shows how they prevented the patient from experiencing a worse outcome.

---

[1] The Joint Commission (2023). Sentinel Event Data Summary. https://www.jointcommission.org/resources/sentinel-event/sentinel-event-data-summary/.

[2] Kelman, Brett (Mar. 22, 2022). As a nurse faces prison for a deadly error, her colleagues worry: Could I be next? National Public Radio. https://www.npr.org/sections/health-shots/2022/03/22/1087903348/as-a-nurse-faces-prison-for-a-deadly-error-her-colleagues-worry-could-i-be-next.