Veteranclaims’s Blog

June 29, 2010

Major Reason VA Physicians Don’t Report Errors?

Filed under: Uncategorized — Tags: — veteranclaims @ 5:01 pm

I must say that this little snippet is eye opening!

Full Article at: If You Have to Be Wrong, How Can You Admit It More Easily?

“As James Bagian, head of the Veterans Administration’s National Center for Patient Safety, told me, “You don’t change the culture [of denial and blame around error] by saying, ‘Let’s change the culture.’ You change the culture by giving people new tools that actually work.”

Such tools exist. Bagian’s own field, medicine, has lately started trying to arm its practitioners with the means and skills to face up to their mistakes. When the VA learned that the major reason clinicians didn’t report errors wasn’t fear of legal action but a feeling of humiliation, they circulated a definition of “blameworthy” harm to a patient that limited such cases to those involving assault, the use of illegal substances, or intentionally attempting obviously dangerous procedures. The result? Error reporting shot up 30-fold. That’s good news for patients: better error reporting translates to fewer errors, since you can’t prevent problems when you don’t know they’re happening. As a result, these kinds of cultural tools turn out to be at least as important for reducing medical error as improvements in technology or information.”

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