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A case for proactive reporting
By Andy Furman, MD, vice president of medical affairs
Most medical errors are not the fault of an individual, but rather of the collective system.
I’m sorry to admit that filling out a PSA has taken me nine months. I’d like to think it took so long because I have been so good in my own processes that I have avoided any errors, and overcome any system level limitations around the care of patients.
The reality is I get caught up in my daily routine and haven’t taken the five minutes to sit in front of a computer and type. I recognized this, and filled in a PSA form about my care and how some improvements could be made.
Of course, I started by blaming myself and replaying in my mind how I could have been so naïve in my diagnostic decision making. But then I looked more globally at the issue’s relation to the system as a whole.
We learned from our medical staff focus groups that the current PSA process feels punitive. We as an organization take this very seriously and prioritized this issue in the current fiscal year Physician Engagement A3.
As those improvement efforts continue, consider doing what I did and self-report. There were many opportunities where a better system would have helped me with my patient. But until there is awareness of an issue, no improvements can be made. Yes, you could wait for someone to do it for you, or worse, hear about it weeks later because your treatment was being questioned by others. Why not recognize up front an outcome could have been better, or a near miss a learning opportunity that could help another colleague?
Access the intranet home page and under Tools and Resources, click Patient Safety Alert. Let me know how the entry process worked for you, or areas that could be improved.
Thank you. You matter. Maybe even more than you realize sometimes.