Error Recognition & Reporting in Healthcare

Error and Critical Event Recognition & Reporting Using QM System Instruments

• The focus lies on recognizing errors and critical events and reporting them using the instruments of the Quality Management (QM) system.
• This is essential for improving patient safety.
• Errors are recognized, security-related events are noted, and this knowledge is used to improve safety.
• Reporting systems are known and used.
• Trainees' actions are aligned with legal requirements and quality criteria.

Overview of Error Handling

• Dealing with errors
• Types of errors in hospitals
• Reason's error model
• Error culture

Fear of Errors

• The error culture in Germany was focused on avoiding errors for a long time.
• People are conditioned to focus primarily on their mistakes rather than their accomplishments.
• This influences the perception of results.

Basic Error Concept

• From the beginning of human history, people have been faced with errors.
• Humans make errors, recognize errors, and learn from them.
• Errors provide an opportunity for chance and improvement.
• Error is defined as something that is wrong or deviates from what is correct, creating incorrectness.
• Errors can be mistaken decisions, measures, or faults, representing a bad quality or lack in a manufactured product.
• Not every error causes negative reactions.
• Inaction can also be considered an error.
• Error can happens consciously or unconsciously.

Understanding and Assessment of Errors

• What constitutes an error depends on individual perception.
• Inevitable actions or omissions do not constitute errors.
• The context of the alleged error must be considered.
• Consider the goals of the person involved to assess if their actions were appropriate.

Error in Hospitals

• Hospitals, under the Action Alliance for Patient Safety, defines errors as any action or omission that deviates from a plan, whether there is a flawed plan.
• It involves situations where a planned action is not followed or where the plan is flawed.
• Error can occur at the execution or planning level

Error Types and Causes

• Execution level errors include attention failures due to distraction or omissions, mistakes due to confusing steps, incorrect sequencing, or acting at the wrong time
• Memory failures due to skipping steps, forgetting standards, or forgetting the intention.
• Plan level errors include knowledge rule-based failures, arising from incorrect procedures, acting at the wrong time, or unawareness.
• Conscious deviations are those arising due to routine, optimization, or situational conditions.

James Reason's Error Model

• James Reason (1938-2025) was a professor of psychology who studied the connection of causes in human error
• Developed the "Swiss Cheese Model".
• Reason's model assumes that safety systems are composed of multiple protective barriers.
• Every barrier has weaknesses (“holes”).
• If the protective barrier holes line up, an error will make it through all the barriers to cause damage.
• Active errors are directly caused by people.
• Latent errors are systemic defects that encourage errors over time.
• Errors occur through a chain of combined circumstances which can be prevented.
• When multiple safety barriers have gaps that align, errors can form a chain resulting in failure.
• To prevent errors, several protective mechanisms must interconnect.
• Accidents are multi-factorial.
• Critical events in a hospital almost always have cause from more than one area.
• Contributing causes can be geographically and temporally remote from the event.
• Problems are recognized as hazards only when they combine with local factors to cause an incident.
• Problems are the consequences of conditions.

Error Culture

• It describes the guiding principles and values that determine how errors are handled in a company.
• A distinction is made between positive (systemic) and negative (person-centered) error cultures.
• Not every mistake is an opportunity for learning.
• Mistakes that began out of carelessness or intent should have consequences
• This also applies if the same mistake is made several times.

Negative Error Culture

• Characterized by errors being stigmatized or punished
• Negative culture is not used for improvement.
• People who report their own errors are blamed when things go wrong.
• Negative culture prevents open communication, motivates concealment, erodes team trust, and deflects accountability

Negative error culture in medicine

• In medicine, the culture tends to place blame and considers errors as primarily personal failures
• The errors that are recognized are often covered up for fear of legal consequences.
• A person-oriented perspective believes that if a person makes a mistake, they did not try hard enough, and they must be more careful in the future.
• They also think that if one points out people’s mistakes, fewer mistakes in the future will be made.

Positive Error Culture

• The positive culture is how a company handles errors from system-oriented perspective
• It Promotes frankness and openness.
• Mistakes are openly communicated & not concealed.
• Creates an environment of trust & cooperation.
• Mistakes are not punished.
• Errors are looked at as an opportunity for improvement and development.
• Positive culture takes Responsibility as Jeder accepts responsibility and actively searches for solutions.
• Communal learning has errors are jointly analyzed to avoid future problems & strengthen teams.
• Takes measures to prevent errors through preventative processes & training.
• The system-oriented approach examines errors and analyzes the outcome.
• Examines underlying system and individual factors.
• Fosters open discussion of errors which searches for solutions.
• Offers reporting structures within the treatment of errors.
• The inhibition threshold to talk about errors decreases when looking for reasons instead of culprits.
• People don’t have to be afraid once reported
• Clear structures exist when dealing with errors
• Error reports are all treated confidentially.
• Errors should be communicated constructively, neutrally, and openly.
• You should ask for advice when unsure.
• Advice/help is given without prejudice about real/alleged errors