After numerous accidents and deaths, in 1976, the Federal Aviation Administration launched the Aviation Safety Reporting System (ASRS) to collect data on all errors, mishaps, and mistakes in commercial and private aviation. From pilot captains to flight attendants to baggage handlers, the ASRS empowers everyone working in the aviation industry to report on any obvious or questionable errors seen during their shifts.
While the government collected similar yet incomplete information many years prior, it failed to analyze it sufficiently. It is only in the current reporting system that all workers submit reports with strict confidentiality, and a third, neutral party, NASA, manages the system. Safety experts attribute the remarkable safety record of civilian aviation over the past decades to the knowledge gained from analyzing the reporting data.
Error Reporting Lacking
Despite the efforts of many individuals and organizations, U.S. healthcare lacks a similar error reporting system. Instead, we rely upon litigation using malpractice claims to identify poor outcomes and deliver compensation. Instead of a focus on prevention, the focus is on monetary reward as compensation for injury or death. In the process, we learn little about how to make the system and the delivery of patient care safer with improved outcomes and lower costs.
A recent article in the N.Y. Times describes poorly trained surgeons using Facebook and YouTube videos to learn how to do complicated hernia repair surgery rather than being correctly taught by experienced instructors. In addition, medical device companies with financial incentives primarily train surgeons to drive the utilization of their devices rather than focus on delivering necessary, high-quality care. These incentives lead to wrong surgeries done by improperly trained surgeons. This lack of oversight and reporting generates unacceptable clinical outcomes and wastes money.
I propose two solutions. First, we must tighten how we offer privileges in our hospitals. As physicians must demonstrate competency to perform various procedures in a hospital – not every general surgeon has operating room privileges to transplant a heart – physicians must demonstrate competency to perform complex procedures by completing a training course deemed acceptable by an oversight body consisting of independent experts.
Second, it is time we followed the lead of aviation and established patient safety reporting systems that allowed everyone in healthcare to submit anonymous reports of errors, near misses, and harm so we can learn the root cause of those problems and take steps to eliminate them. An independent, neutral party, walled off from malpractice litigation, must manage the system.
If those submitting reports believed they would be open to malpractice suits or retribution by an employer, they would be reluctant to participate. And with those independent, anonymous reports, we will be able to learn how to take those leaps to make our healthcare system safer for patients.
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