(Press-News.org) "Too busy," and "too complicated." These are the typical excuses one might expect when medical professionals are asked why they fail to use online error-reporting systems designed to improve patient safety and the quality of care. But, Johns Hopkins investigators found instead that the most common reason among radiation oncologists was fear of getting into trouble and embarrassment.
Investigators e-mailed an anonymous survey to physicians, nurses, radiation physicists and other radiation specialists at Johns Hopkins, North Shore- Long Island Jewish Health System in New York, Washington University in St. Louis, Missouri, and the University of Miami, with questions about their reporting near-misses and errors in delivering radiotherapy. Each of the four centers tracks near-misses and errors through online, intradepartmental systems. Some 274 providers returned completed surveys.
According to the survey, few nurses and physicians reported routinely submitting online reports, in contrast to physicists, dosimetrists and radiation therapists who reported the most use of error and near-miss reporting systems. Nearly all respondents agreed that error reporting is their responsibility. Getting colleagues into trouble, liability and embarrassment in front of colleagues were reported most often by physicians and residents.
More than 90 percent of respondents had observed near-misses or errors in their clinical practice. The vast majority of these were reported as near-misses as opposed to errors, and, as a result, no providers reported patient harm. Hospitals have specific systems for reporting errors, but few have systems to accommodate the complex data associated with radiotherapy.
"It is important to understand the specific reasons why fewer physicians participate in these reporting systems so that hospitals can work to close this gap. Reporting is not an end in itself. It helps identify potential hazards, and each member of the health care team brings a perspective that can help make patients safer," says Johns Hopkins radiation oncology resident Kendra Harris, M.D., who presented an abstract of the data on October 2, 2011, at the 53rd Annual Meeting of the American Society for Radiation Oncology (ASTRO).
The good news, Harris says, is that few respondents reported being too busy to report or that the online tool was too complicated. "Respondents recognized that error events should be reported and that they should claim responsibility for them. The barriers we identified are not insurmountable," she added.
Harris says that online reporting systems should be simple and promoted as quality improvement tools, not instruments for placing blame and meting out sanctions. "These systems should not be viewed as punitive; rather, they're a critical way to improve therapy," says Harris. "You can't manage what you can't measure."
Most of the respondents said they would participate in a national reporting system for radiotherapy near-misses and errors.
"A national system that collects pooled data about near-misses and errors, which are thankfully rare, may help us identify common trends and implement safety interventions to improve care," adds Harris.
INFORMATION:
No funding resources, apart from time spent by the investigators, were utilized for this research. Oversight of the research was provided by Stephanie Terezakis and Eric Ford at Johns Hopkins. In addition to Harris, Terezakis and Ford, investigators involved in the research included L. Potters and R. Sharma at North Shore-Long Island Jewish Health System; S. Mutic and H. Gay at Washington University in St. Louis; and J. Wright and M. Samuels at the University of Miami.
On the Web:
ASTRO annual meeting: www.astro.org/annualmeeting
Abstract Title: "Learning From Our Mistakes: A Multi-Institutional Survey of Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting"
END
A team of scientists, led by Johns Hopkins researchers, say they may have found a way to predict how quickly patients with Alzheimer's disease (AD) will lose cognitive function by looking at ratios of two fatty compounds in their blood. The finding, they say, could provide useful information to families and caregivers, and might also suggest treatment targets for this heartbreaking and incurable neurodegenerative disorder.
Past research has shown that cognitive function declines at different rates in AD patients, with roughly one-third not declining at all in five years, ...
A new study from the University of Adelaide shows the parents of women with polycystic ovary syndrome (PCOS) are more likely to have some form of cardiovascular disease.
PCOS is a hormonal disorder affecting about 10% of women of reproductive age. It is one of the most common endocrine disorders in women and a leading cause of infertility.
The study shows mothers of women with PCOS are more likely to have any form of cardiovascular disease, and almost twice as likely to have high blood pressure, than mothers of other women.
Fathers of women with PCOS are more than ...
ST. PAUL, Minn. – People who rate their health as poor or fair appear to be significantly more likely to develop dementia later in life, according to a study published in the October 5, 2011, online issue of Neurology®, the medical journal of the American Academy of Neurology.
"Having people rate their own health may be a simple tool for doctors to determine a person's risk of dementia, especially for people with no symptoms or memory problems," said study author Christophe Tzourio, MD, PhD, director of the Inserm unit 708 Neuroepidemiology at the University of Bordeaux ...
STANFORD, Calif. -- North American babies who acquire toxoplasmosis infections in the womb show much higher rates of brain and eye damage than European infants with the same infection, according to new research from the Stanford University School of Medicine.
Eighty-four percent of the North American infants studied had serious complications of the parasitic infection, including calcium deposits in the brain, water on the brain and eye disease that caused visual impairment or blindness. By contrast, few European infants had these problems -- for instance, about 17 percent ...
CHAMPAIGN, Ill. — Scientists call it LUCA, the Last Universal Common Ancestor, but they don't know much about this great-grandparent of all living things. Many believe LUCA was little more than a crude assemblage of molecular parts, a chemical soup out of which evolution gradually constructed more complex forms. Some scientists still debate whether it was even a cell.
New evidence suggests that LUCA was a sophisticated organism after all, with a complex structure recognizable as a cell, researchers report. Their study appears in the journal Biology Direct.
The study ...
(Deerfield, Ill., USA – October 5, 2011) Indoor spraying with the insecticide bendiocarb has dramatically decreased malaria transmission in many parts of Benin, new evidence that insecticides remain a potent weapon for fighting malaria in Africa despite the rapid rise of resistance to an entire class of mosquito-killing compounds, according to a study published today in the October edition of The American Journal of Tropical Medicine and Hygiene.
Scientists with Benin's Entomologic Research Center in Cotonou evaluated the effects of two applications of bendiocarb in ...
STANFORD, Calif. — Investigators at the Stanford University School of Medicine have developed a novel protocol that allows kidney-transplant recipients to jettison their indispensable immune-suppressing drugs. The protocol could also spell substantial savings to the health-care system.
The researchers have reported their progress in a letter that will be published Oct. 6 in the New England Journal of Medicine. Eight of the 12 patients discussed in the small study have now been off of immunosuppressant drugs for at least one year, and in some cases for longer than three ...
New research suggests that small "seed" amounts of diseased brain proteins can be taken up by healthy neurons and propagated within them to cause neurodegeneration. The research, published by Cell Press in the October 6 issue of the journal Neuron, sheds light on the mechanisms associated with Parkinson's disease (PD) and provides a model for discovering early intervention therapeutics that can prevent or slow the devastating loss of neurons that underlies PD.
Alpha-synuclein (α-syn) is a brain protein that forms abnormal, neuron-damaging intracellular clumps called ...
Our behavior is often guided by the desire to obtain positive outcomes and avoid negative consequences, and neuroscientists have put a great deal of effort into looking for reward and punishment "centers" in the brain. Now, new research published by Cell Press in the October 6 issue of the journal Neuron reveals that neural signals related to reinforcement and punishment are far more broadly distributed throughout the entire human brain than was previously thought.
Understanding the neural basis of reinforcement and punishment processing is of paramount importance to ...
BOSTON –Over the past decade, new technologies have revealed that autism spectrum disorder has a substantial genetic component. But determining exactly which genes are involved has been like finding the proverbial needle in the haystack.
Now a research team from Beth Israel Deaconess Medical Center (BIDMC) has created a genetically engineered mouse with increased dosages of the Ube3 gene. And, like the patients who also harbor increased dosages of this single gene, the genetically engineered mice exhibit robust examples of all three traits considered hallmarks of autism: ...
