New System for Patients to Report Medical Mistakes Could Be Potential Disaster

According to a New York Times report, the Agency for Healthcare Research and Quality (AHRQ) has developed a new proposed program that is intended to complement safety reports already being submitted by providers, including doctors and hospitals, with those from patients and their relatives. This proposed reporting system, would allow patients and family members to “report medical errors and near misses through a website and in telephone interviews.” For each case, the government hopes to find out “what happened; details of the event; when, where, whether there was harm; the type of harm; contributing factors; and whether the patient reported the event and to whom.”

As detailed in the New York Times article, Kevin J. Bozic, Chairman of the Council on Research and Quality at the American Academy of Orthopedic Surgeons, made a great point and stressed the importance of matching information in patients’ reports with that in the medical record. He said,

“Patients’ perceptions and experience of care are very important in assessing the overall success of medical treatments. However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge. For instance, a patient may say, ‘I had an infection after surgery’ because the wound was red. But most red wounds are not infected. Or a patient says, ‘My hip dislocated’ because it made a popping sound. But that’s a normal sensation after hip replacement surgery. Patients’ perceptions and experience of care are very important in assessing the overall success of medical treatments. However, patients may mischaracterize an outcome as an adverse event or complication because they lack specific medical knowledge.”

While we here at Neurosurgery Blog are all for patient-shared decision making, we share Dr. Bozic’s concerns and fear that this new proposal from the administration could be a potential disaster.  Rather than fostering an environment of non-punitive patient safety/quality improvement, it will potentially empower a new unknowledgeable patient police force and in the end will not necessarily do anything to reduce errors or improve quality of care.

As it turns out, a handful of physician lawmakers agreed with us and sent a letter to AHRQ Director, Carolyn Clancy registering concerns and posing a number of questions about the proposed policy. The letter was signed by Sens. Tom Coburn, MD (R-OK) and John Boozman  (R-AR) and Reps. Bill Cassidy, MD (R-LA); Ron Paul, MD(R-TX); Phil Gingrey, MD (R-GA); Paul Broun, MD (R-GA); John Fleming, MD (R-LA); and Phil Roe, MD (R-TN).  In addition, the American Medical Association (AMA) also submitted a letter addressing their concerns over the proposed prototype consumer reporting system.

We all know the saying “the devil is in the details” and it remains to be seen what the future is for this program (the comment period ends November 9), but if it does move forward we should all take jobs in risk management, as this clearly will increase demand for those programs.

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