http://bmj.com/cgi/content/full/323/7308/298
BMJ 2001;323:298 ( 11 August )
Anonymous reporting has an important role
In spite of this recent recognition of the need for monitoring, disagreement
remains about the attributes of the ideal reporting system. There
are at least two distinct objectives. One is to identify
practitioners or units whose performance is substandard and
processes, infrastructure, or equipment that are manifestly inadequate
or dangerous and to deal with these particular problems at a local
level. To do this systematically will require the collection of data
and numerators and denominators. Units and individuals will need to
be identified. Information such as batch numbers, manufacturers'
names, and models will be needed. The requirements of natural
justice dictate that this process be objective and properly
validated. With careful attention to safeguards, selected information
of this sort could and should be made publicly available. However,
this approach identifies the problem in only a relatively small
proportion of the many cases where things go wrong in health care.
There is also a wide range of events for which the frank reporting of all
the relevant details may damage the professional prospects and
working relationships of those involved. Reluctance to report in
these circumstances persists in spite of moves towards greater
openness in the workplace. A doctor is unlikely to report if he or
she knows that this information, associated with his or her name,
will be retained somewhere in a file or databank. Assurances of
confidentiality may not be enough; those who know how diluted the
principle of medical confidentiality has become might be forgiven
for questioning whether highly incriminating information passed on
to hospital authorities will go no further. If reporting is
anonymous, however, such a doctor will have nothing to lose and
might be more motivated to report the problem to prevent its recurrence.
A fundamental principle is that while rare problems are not foreseeable and
may never manifest themselves again in exactly the same way, the
contributing factors behind them often are foreseeable and can be
systematically identified and addressed. This is the second
objective of incident reporting. The most important goal here is to
gather the necessary information about where and why things are
likely to go wrong rather than to identify the people involved. This
recognises that most avoidable problems in complex organisations
relate more to faults in the system than to faults in the
individual.3
There is a strong case in these circumstances for anonymous
reporting, in which individuals are neither required to identify
themselves nor allowed to identify others. This opens the way for
opinions about human performance to be expressed without fear of
legal or professional consequences.
A frequent objection to this approach is that those involved may have
misinterpreted facts or failed to identify important contributing
factors and that, without independent follow up, this information would
be lost. Australian experience with many thousands of anonymous
reports suggests that this is only occasionally a problem and is
more than compensated for by a rich mass of "human factors"
information that would not otherwise be recorded.4 There
is also some middle ground: many who file anonymous reports are
quite happy also to own up to them at quality assurance meetings with
peers, allowing both discussion of possible alternative interpretations and
independent validation of the facts.
A widely held misconception is that allowing anonymity confers a special
privilege on doctors. A system of anonymous incident reporting does
not replace any existing legal or disciplinary processes that may
follow harm to a patient. These processes are an important part of
responding to the needs of those who have been injured, but they
have a minor role in improving patient safety overall. Anonymous
reporting should be seen as adding a safety component to existing
legal and complaints procedures. It gives doctors nothing that they
do not already have; it takes nothing away from the rights that
patients currently enjoy; and it provides an additional, powerful,
and currently unavailable tool for making health care safer.
No system will work adequately unless those from whom the reports are needed
are fully engaged and their legitimate concerns addressed. We
believe that, as a minimum, a trial of reporting systems which
include an anonymous option should be undertaken within the National
Patient Safety Agency of the NHS.
Bill Runciman
Australian Patient Safety Foundation, GPO Box
400, Adelaide, South Australia 5001, Australia (wrunciman@medicine.adelaide.edu.au)
Alan Merry
Department of Anaesthesia, Green Lane
Hospital, Auckland, New Zealand
Alexander McCall Smith
Faculty of Law, University of Edinburgh,
Edinburgh EH8 9YL (mccallsmith@btinternet.com)
Footnotes
AM has financial interests in Safer Sleep Limited, which
promotes a system for reducing errors in anaesthesia.
|
1. |
Department of Health. An organisation with a memory:
report of an expert group on learning from adverse events in the NHS chaired
by the Chief Medical Officer. London: Stationery Office, 2000. |
|
2. |
Institute of Medicine. To err is human: building a
safer health system. Washington DC: National Academy Press, 2000. |
|
3. |
Reason JT. Human error. New York: Cambridge
University Press, 1990. |
|
4. |
Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P,
Russell WJ, et al. The Australian Incident Monitoring Study: an analysis of
2000 incident reports. Anaesth Intensive Care 1993; 21: 520-528 |
© BMJ 2001
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