Lost opportunities: how physicians communicate about medical errors.
This AHRQ-funded study surveyed more than 1000 physicians to understand their beliefs about error reporting and their use of current reporting systems. More than half the respondents reported involvement in a serious error with a similar proportion agreeing that system failures, rather than individual ones, are the cause. Most physicians did describe the use of formal reporting systems but felt they were largely inadequate mechanisms to both communicate and prevent errors. The authors conclude that physicians are in fact engaged in discussing errors but that current systems promote communicating these events through avenues that may not capture them at an institutional level, such as reporting them to a colleague. A past AHRQ WebM&M perspective discussed the experiences and success of the Minnesota adverse health events reporting system.