Now, keep up to date
with daily feeds of newly posted stories
about America's Seniors...click on the box
Preventable Hospital Deaths can be reduced
by encouraging Error Reporting
Newswise, May 2010 — People go to hospitals
to be treated for an illness or for
corrective surgery with the expectation they
will return home in much better health than
when they entered the medical facility.
The reality, though, is that many may never
recover or return home. A 2009 study by
Hearst newspapers estimated the death toll
from preventable medical mistakes is nearly
200,000 annually in the United States.
That’s not much different than a 2004 report
from HealthGrades, a healthcare quality
organization, showing that in the three
previous years, about 195,000 Americans died
each year; the result of preventable medical
practices in hospitals.
One way of lowering those numbers is to
reform the way errors are reported, which in
this country are often beset by complex and
contentious procedures, according to the
Improvements in hospital safety practices
begin with the reporting of errors and
potential mistakes in the care of patients,
said Dana E. Sims, who focused a study on
the influence of a learning orientation
culture within an organization and trust in
leadership on workers’ willingness to
formally report and document errors.
Sims, who conducted the study for doctoral
dissertation at the University of Central
Florida in 2009, presented her findings
earlier this month at the Society for
Industrial and Organizational Psychology’s
annual conference in Atlanta.
There is no uniform reporting among states
in regard to releasing information about
In March the Inspector General of the
Department of Health and Human Services
issued a report that indicated hospitals are
not consistent in gathering information
about preventable medical errors because of
inadequate hospital data and poor internal
tracking of medical errors by hospitals
Accurate reporting of errors depends upon
whether organizations encourage, support and
follow up the documentation of errors and
practices that can harm patients. Also,
compiling information relies heavily on
front-line employees, nurses and medical
staff, being able to report mistakes within
a non-threatening culture.
“It’s important to identify and adapt
procedures that are unsafe and potentially
can lead to serious mistakes,” said Sims.
“If hospital administrators are unaware of
mistakes and unsafe practices, they cannot
do anything about them.”
Too often healthcare workers believe error
reporting is a sure path to trouble that
will result in blame and punishment to those
On the other hand, some hospitals will avoid
finger-pointing and instead take a holistic
view of where the systemic failure may have
occurred, said Sims.
Her study of care units within two hospitals
found that organizations and leaders who
promote a “learn from our mistakes” culture
may bolster employees’ decisions to openly
“A smart organization knows that employees
are aware of practices and incidents on the
front-line that the administration does not
want to hear.
"But the administration needs
to encourage employees to report them anyway
to avert disaster,” Sims said. Sometimes top
leaders are too insulated from what is
happening within the organization, she
“In the long term, hearing what employees
have to say can save lives as well as
prevent expensive lawsuits and damages to a
hospital’s reputation,” she said.
She found that perceptions about the
organization are the strongest predictor of
whether employees’ tend to document errors.
Establishing an organizational learning
climate is important to sound reporting
practices, said Sims.
organizational climate is a shared
perception by workers of what is valued and
expected in the work environment based upon
the norms, policies and procedures set by
Without those organizational standards,
teams tend to make excuses, become defensive
and punish and blame others.
environment should be promoted where
mistakes are viewed as an opportunity to
improve team performances and openly discuss
errors and potential mistakes, she said in
her SIOP presentation.
The most common hospital mistakes are
shortcuts or workarounds that medical staffs
use in an effort to be more efficient in
their work. Some of these basic at-risk
behaviors could include failure to properly
identify patients or to verify prescription
dosages and inaccurate documentation of
vitals, Sims said.
These are often done by experienced nurses
who have handled these kinds of task
previously and are convinced that a shortcut
is acceptable. But in most cases it is not
the right thing to do.
A blaming culture is not good for the
organization. “Human mistakes are different
than reckless practices,” Sims pointed out.
“Sometimes in health care, with its
accompanying stresses, there is a propensity
to work around procedures in an effort to be
more efficient. Rules and procedures are
there for a reason and are intended to
increase patient safety,” she added.
“Individuals have a personal responsibility
when they engage in those workarounds. While
the organization needs to make clear that
they are also accountable for reckless
behavior, it also needs to identify internal
practices that might be encouraging those
work arounds to be used,” Sims said.
Hospitals can benefit by supporting
employees who report practices that can lead
to serious errors and using those reports to
Providing good coaching and mentoring and
making system changes will make a
difference, Sims said.
surprise Sims found in her study was a
difference between an organizational
directed learning environment and a leader
promoted environment. Leaders, said Sims,
are those people responsible for units
within the organization.
“Based upon past research, I didn’t expect
there to be much difference between
perceptions of the leader and the
organization, but the nurses I talked with
said there often is a difference.
leaders have varying leadership styles and
the way they interpret or put into practice
organizational policies and procedures.
are unwavering in following the procedures
while others are more relaxed. In short,
some filter the organizational policies,”
“Healthcare organizations should place
increased emphasis on what is done with the
information gathered from error reporting
systems,” Sims’ study concluded.
“Specifically, organizations must ensure
that employees know they are being heard,
that systemic problems identified via error
reporting are addressed by the organization,
and that employees who admit to and/or
identify errors are helping the organization
to create a climate of safer medical care,”
Further, leaders at the point of care play
an important role in their team’s
willingness to document errors.
Organizations must ensure their leaders have
the skills necessary to reinforce learning
oriented responses to errors within their
units, Sims said.
Without these (and other) changes, needless,
avoidable deaths will continue unabated in
the nation’s hospitals and care facilities.
The Society for Industrial and
Organizational Psychology (SIOP) is an
international group of more than 7,800
members study and apply scientific
principles concerning workplace
productivity, motivation, leadership and
SIOP’s mission is to enhance human
well-being and performance in organizational
and work settings by promoting the science,
practice and teaching of I-O psychology.
For more information about SIOP, including a
Media Resources service that lists nearly
2,000 experts in more than 100 topic areas,