Improving
transparency around medical error is a potential “magic bullet” that
could finally start to make health care less hazardous after years of
lacklustre efforts, concludes a new report from a major American
patient-safety organization.
Increasing openness would bring “powerful effects” and cost relatively little to implement, the National Patient Safety Foundation report argues.
Among the institute’s 39 recommendations is for health care
institutions to create a culture where transparency is rewarded and
failing to speak up brings “consequences”; informing all patients about
their clinician’s experience, outcomes and disciplinary history; and
requiring that hospitals and other facilities publicly report on their
performance.
“If transparency were a drug, it would likely be a blockbuster, given the evidence of its effectiveness and its enthusiastic endorsements from key stakeholders,” said the organization. “How can patients fully trust the clinicians and organizations from which they receive care if these clinicians and organizations are not fully transparent?”
The report from the foundation’s Lucian Leape Institute was released this week, as a National Post series revealed that most of the thousands of cases of serious medical error estimated to occur in Canadian hospitals every year go unreported even within the facilities. And less information about those mishaps is divulged publicly.
Four provinces release no data at all, most of the rest provide only limited statistics. Manitoba alone releases any detail — in the form of terse, one-line descriptions — on specific incidents.
The foundation notes that, if anything, the rate of medical error has grown worse since the U.S. Institute of Medicine first published a study 15 years ago estimating the extent of the problem.
It was followed in Canada in 2004 with a study that estimated about 70,000 preventable, serious adverse events occur in acute-care hospitals annually, with 9,000 to 23,000 patients dying because of avoidable errors.
Efforts to fix the problem, including education programs, computerization, changes to organizational culture and root-cause analysis, have had limited impact, says the American report, called Shining a Light.
But exposing the system to further scrutiny – “the free, uninhibited flow of information that is open to the scrutiny of others” — could make a real difference, it argues.
“We believe the missing ingredient, the essential element needed to enable the operational and culture changes to occur, is transparency,” said the institute. “Patients have a right to full information about every aspect of their care. Without it, optimal care is an elusive dream.”
Research suggests that releasing information about the outcomes of health care leads to better practices, the report said, and is more effective than, say, offering incentive payments for good performance, an increasingly popular concept in Canada.
The report warned, however, there are many barriers to increased openness, such as fear of harm to reputation, livelihood or pride; and the desire of some players in the system to maintain the status quo and “resist the sharing of information.”
But deliberate withholding of information puts patients at risk and represents a “moral failure,” the report said.
National Post
• Email: tblackwell@nationalpost.com | Twitter: tomblackwellNP
Source: http://news.nationalpost.com/2015/01/22/transparency-about-medical-errors-a-magic-bullet-that-could-help-make-heath-care-safer-report/
Increasing openness would bring “powerful effects” and cost relatively little to implement, the National Patient Safety Foundation report argues.
“If transparency were a drug, it would likely be a blockbuster, given the evidence of its effectiveness and its enthusiastic endorsements from key stakeholders,” said the organization. “How can patients fully trust the clinicians and organizations from which they receive care if these clinicians and organizations are not fully transparent?”
The report from the foundation’s Lucian Leape Institute was released this week, as a National Post series revealed that most of the thousands of cases of serious medical error estimated to occur in Canadian hospitals every year go unreported even within the facilities. And less information about those mishaps is divulged publicly.
Four provinces release no data at all, most of the rest provide only limited statistics. Manitoba alone releases any detail — in the form of terse, one-line descriptions — on specific incidents.
The foundation notes that, if anything, the rate of medical error has grown worse since the U.S. Institute of Medicine first published a study 15 years ago estimating the extent of the problem.
It was followed in Canada in 2004 with a study that estimated about 70,000 preventable, serious adverse events occur in acute-care hospitals annually, with 9,000 to 23,000 patients dying because of avoidable errors.
Efforts to fix the problem, including education programs, computerization, changes to organizational culture and root-cause analysis, have had limited impact, says the American report, called Shining a Light.
But exposing the system to further scrutiny – “the free, uninhibited flow of information that is open to the scrutiny of others” — could make a real difference, it argues.
“We believe the missing ingredient, the essential element needed to enable the operational and culture changes to occur, is transparency,” said the institute. “Patients have a right to full information about every aspect of their care. Without it, optimal care is an elusive dream.”
Research suggests that releasing information about the outcomes of health care leads to better practices, the report said, and is more effective than, say, offering incentive payments for good performance, an increasingly popular concept in Canada.
The report warned, however, there are many barriers to increased openness, such as fear of harm to reputation, livelihood or pride; and the desire of some players in the system to maintain the status quo and “resist the sharing of information.”
But deliberate withholding of information puts patients at risk and represents a “moral failure,” the report said.
National Post
• Email: tblackwell@nationalpost.com | Twitter: tomblackwellNP
Source: http://news.nationalpost.com/2015/01/22/transparency-about-medical-errors-a-magic-bullet-that-could-help-make-heath-care-safer-report/
