Proper reporting reflects culture, not mandates

By Dr. Mark Valliere and Sherrie Justice

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The Obama administration recently announced a broad initiative to reduce medical errors. As health care providers for our community and advocates for patients seeking quality care, we share that goal.

According to the Institute of Medicine, medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Among the problems that may occur during the course of providing health care are adverse drug events and improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers and mistaken patient identities.

It is important for health care organizations to look for the underlying causes and contributing factors to errors that occur, and try to redesign systems and processes to prevent further errors. Technology, such as electronic medical records, often plays an important role. Understanding human error and using information technology to support change is critical to making care safer.

As affiliates of the Iowa Hospital Association, Mercy Medical Center and St. Luke's Hospital are longtime advocates for voluntarily reporting patient safety and quality information.

Both Cedar Rapids hospitals have been active participants with the Iowa Healthcare Collaborative since its inception in 2005 to increase public availability of health care performance information. Government regulation does not create the same kind of buy-in. In some cases, it can stifle innovation as providers focus on meeting the mandate and little more.

Both St. Luke's and Mercy are accredited by The Joint Commission, which is an independent, not-for-profit organization. The Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.

If a medical error or sentinel event should occur, both Mercy and St. Luke's voluntarily report it to The Joint Commission. It's the right thing to do to allow all hospitals to learn from the medical errors of others.

When a “sentinel event” or “medical error” occurs, St. Luke's and Mercy report this event to The Joint Commission. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. In the event of a sentinel event, medical error or near-miss, Mercy and St. Luke's inform the patient and their family and pursue a root-cause analysis. This analysis includes assembling the team that cared for the patient and a thorough investigation is launched to learn from the incident and determine what corrective actions are needed to avoid reoccurrence.

There is much debate over whether mandatory federal or state laws should be enacted for the reporting of medical errors. If patients in our care are injured or harmed as a result of a medical error, it is our obligation to find the cause and put measures in place to prevent it from happening again.

It boils down to the culture of an organization. We want to promote a culture of safety in which our staffs feel comfortable telling us about errors and “near misses” so that processes can be improved.

Dr. Mark Valliere is Senior Vice President of Medical Affairs & Chief Medical Officer at Mercy Medical Center in Cedar Rapids. Comments: mvallierea@mercycare.org. Sherrie Justice is St. Luke's Hospital Director of Performance Improvement. Comments: justicsl@crstlukes.com. Valliere and Justice submitted this guest column on behalf of St. Luke's and Mercy as a joint response.