Editor’s Notebook: Learning from Our Mistakes

Susan Carr

Editor, susan.psqh@gmail.com

In simplest terms, the adage that we must learn from our mistakes is the core principle of the patient safety movement. Acknowledging that human error is inevitable opens the door to improvement. Progress starts with analyzing errors, understanding how to make systems safer and more reliable, and then sharing that knowledge throughout organizations to protect patients from being harmed in the future.

Learning from mistakes in patient care is complex. Before learning can happen, errors and near misses must be recorded and defined systematically. Especially with electronic reporting, the volume of data may overwhelm an organization’s ability to digest, analyze, and act. The Institute of Medicine’s report, To Err is Human (Kohn, Corrigan, & Donaldson, 2000), identified incident reporting as a core activity for safety improvement. Fifteen years later, 90% of hospitals use some kind of incident reporting system (Mitchell, Schuster, Pronovost, & Wu, 2015), but debate continues about what to report, how to use the data, and whether the systems are being used effectively to improve patient safety. Carl Macrae (2015), a social psychologist in England, observes, “Analyzing incidents does not itself produce learning” (p.3). Learning comes from the complex work of people in organizations discovering together how to make care delivery safer and sustain those improvements.

In this issue of PSQH, a number of articles reflect different aspects of incident reporting. In the cover story, Greenberg, Ranum, and Siegal include brief descriptions of four malpractice cases to illustrate problems with breast cancer diagnosis or treatment. Unfortunately, in these cases, the reporting and learning come after harm has occurred. These are actual cases, de-identified, and reported without disclosing the ultimate disposition of each case, which doesn’t diminish the learning. Knowing who may have settled or been found guilty or innocent in each is irrelevant to the value these stories have for learning and improvement.

In our sponsored Industry Focus section, Tom Inglesby interviews executives from companies that provide incident reporting systems. Their current focus is on learning from near misses and analyzing the copious data these systems gather so as to help organizations be as proactive as possible in preventing harm.

Robert Oshel reviews the history of the National Practitioner Data Bank on its 25th anniversary. The reports contained in the Data Bank — malpractice payments and medical disciplinary actions–are not incident reports per se. Arguably, these are the opposite of the cases related by Greenberg, Ranum, and Siegal; in the Data Bank, the final disposition is all that is known. Alongside safety and quality improvement efforts, a robust process for licensing and credentialing physicians and other practitioners should provide assurance that organizations are delivering the best care possible. Let’s hope that each Data Bank report represents an opportunity that was used to learn and improve.