Patient safety: Communication and error reporting

When medical errors result in adverse events, healthcare teams have three important responsibilities after ensuring the patient’s safety. The first one is error reporting. The error must be detected and reported so that health systems can examine unsafe processes and improve patient safety.

The next one involves error disclosure and communication to the patient and family in a clear and compassionate way.

And finally, healthcare organizations provide organizational support to clinicians in the aftermath of errors and adverse events, understanding the emotional toll on healthcare workers themselves.

Together, these processes help transform medical errors and adverse events into opportunities for system-level learning and improved patient safety outcomes.

Let’s start with error reporting. The main challenge here is underreporting. Healthcare professionals may hesitate to report errors for many reasons, including embarrassment, fear of punishment, or time limitations due to busy schedules. Because of this, healthcare systems need to create error-reporting workflows that are efficient, and psychologically safe workplace environments that encourage transparency.

This brings us to error-reporting systems, which are essential tools for improving healthcare quality and patient safety. These systems help organizations identify unsafe processes and recurrent errors to prevent further harm. Error-reporting systems also promote learning by encouraging healthcare teams to take a closer look at how system and communication failures affect patient outcomes.

Okay, error-reporting systems are either mandatory or voluntary.

Mandatory reporting systems require healthcare organizations or clinicians to report certain adverse events to governmental agencies, accrediting bodies, or regulatory organizations. This can include promoting accountability and public safety by complying with state regulations involving sentinel events. As a reminder, sentinel events are unexpected events that cause serious physical or psychological harm, or even death. A classic example is wrong-site surgery.

To help standardize how serious adverse events are identified and classified, healthcare organizations use frameworks developed by the National Quality Forum, or NQF. The NQF created categories of Healthcare Serious Reportable Events to classify severe patient safety incidents. Many of these events include “never events” because they are considered preventable patient harm.

The first category involves surgical or procedural events, such as surgeries performed on the wrong patient or body part. Next are product or device events, including injuries caused by contaminated medications or malfunctioning equipment. The third category, patient protection events, refers to situations like patient suicide or unsafe patient elopement. Then there are care management events, including medication errors, delayed treatment, or monitoring failures that result in harm. The fifth category is environmental events such as burns, falls, or injuries caused by unsafe healthcare environments. And finally, the sixth category includes criminal events like assault or impersonation of healthcare personnel.

Alright, let’s move on to voluntary reporting systems. Healthcare workers may voluntarily report near misses, unsafe conditions, or communication failures that may not require mandatory reporting. Internal hospital incident reports and anonymous reporting systems are common examples and help improve learning and quality improvement efforts.

Okay, it’s time to go over a case.

Mr. Reynolds, a 54-year-old man with chronic obstructive pulmonary disease, or COPD for short, and hypertension, was admitted to the hospital for worsening shortness of breath and hypoxia caused by an acute COPD exacerbation. While hospitalized, he received supplemental oxygen, bronchodilators, corticosteroids, and close respiratory monitoring. On the second hospital day, Nurse Alison accidentally administered a high dose of an intravenous opioid that was intended for another patient with a similar last name on the same unit.

Shortly afterward, Nurse Alison noted difficulty rousing Mr. Reynolds from sleep, and he had developed respiratory depression with decreased oxygen saturation. She activated a rapid response team, who assessed the patient and determined that he needed naloxone. He was transferred to the intensive care unit for monitoring and stabilization, where his condition improved.

Nurse Alison recognized her mistake and submitted an incident report. The internal incident report functioned as a voluntary reporting mechanism that helped find patient identification failures and medication administration risks.