HCA 675 week 4 discussion 2.
What are the risks of revealing mistakes in an open culture, as a way of being transparent with patients and families? What are the risks of concealing mistakes and errors?
The IOM report also emphasized the importance of reporting errors, using systems to “hold providers accountable for performance,” and “provide information that leads to improved safety.” Conceptually these purposes are not incompatible, but in reality they can prove difficult to satisfy simultaneously1 (p. 156). Nonetheless, reporting potentially harmful errors that were intercepted before harm was done, errors that did not cause harm, and near-miss errors is as important as reporting the ones that do harm patients. Patient safety initiatives target systems-related failures that contribute to errors within the complex environment of health care. Because many errors are never reported voluntarily or captured through other mechanisms, these improvement efforts may fail.
Errors that occur either do or do not harm patients and reflect numerous problems in the system,4 such as a culture not driven toward safety and the presence of unfavorable working conditions for nurses. To effectively avoid future errors that can cause patient harm, improvements must be made on the underlying, more-common and less-harmful systems problems5 most often associated with near misses. Systems problems can be detected through reports of errors that harm patients, errors that occur but do not result in patient harm, and errors that could have caused harm but were mitigated in some manner before they ever reached the patient. Reporting near misses (i.e., an event/occurrence where harm to the patient was avoided), which can occur 300 times more frequently than adverse events, can provide invaluable information for proactively reducing errors.6 Analysis of reported errors have revealed many “hidden dangers” (near misses, dangerous situations, and deviations or variations) that point to system vulnerabilities, not intentional acts of clinician performance that may eventually cause patients harm.