Pediatric Informatics: Computer Applications in Child Health (Health ...

390 D.C. Stockwell and A.D. Slonim
a powerful disincentive to completion of incident reports or objective participation
in an M&M conference. Also these techniques often vary in their identification of
near misses or absorbed events.
Since it is difficult to even encourage error reporting it is therefore almost impossible
to track the number of reports and identify trends. Dependence on incident
report rates as a measure of safety (error rates) is erroneous since the denominator
of errors is not known. Campaigns to empower staff to report without retribution
may help to increase reporting rates. Workplace cultural issues, such as poor staff
morale, perceptions about retribution or leadership inactivity can dramatically
decrease rates. 17 and severely limit staff identification of errors.
Another difficulty with these tools is that while the investigation into the source
of the error, the communication of findings to staff and the translation of actionable
recommendations may be poor or inappropriate. Thus, new procedures, forms and
guidelines the critical phase of explaining the learned lessons to physicians, nurses
and other staff often does not occur. 17–19
Focus on only the most serious events may miss numerous opportunities (nearmisses,
no harm errors or low severity errors) for correcting dangerous situations.
Since all of these methods (except for direct observation) are reactive, recall may
not be precise and may introduce inaccuracies, detection methods may not consider
prevented errors (near misses) and errors that occurred but from which no harm
resulted (absorbed events). 17
Each of these methods is used locally and therefore does not benefit from the
broad range of experiences in a multi-institutional setting to guide error reduction
and safety optimizations. 1,20–22 Few collaborative efforts focus on the multiinstitutional
approach to improving care and formally sharing their strategies.
Currently, patient safety efforts are viewed negatively as inadequacies in care and
as potential opportunities for litigation rather than an opportunity to share information
that can improve safety in the industry. 1,2 Hence, patient safety interventions
need to provide a broader view that takes into account the efforts of multiple
institutions’ ideas and strategies. 1,20–22
30.5 Electronic Solutions
Information technology solutions address some of the limitations of existing error
detection methods. In the airline industry, after recognizing that one of the barriers
to improving safety was poor communication, leadership created a reporting system
whereby members of the industry could learn from previously made mistakes
and avoid repeating similar situations. 23 It was acknowledged that having centralized
reporting would allow all airlines to benefit from the mistakes of others. This
simple method is credited with greatly improving the safety of the airline industry.
In healthcare, individual providers or institutions may learn from past mistakes but
other providers and institutions are forced to make similar errors rather than to learn
from the collective knowledge of the industry. Several factors conspire to limit