Doctors learn from treatment errors

Brochure encourages doctors and nurses to admit treatment errors to patients

01/17/2014

In Germany, about 18,000 patients die due to treatment errors in the hospital. However, experts estimate the number of unreported cases to be much higher, as health care errors are often swept under the carpet. Doctors and nurses fear the consequences. A new AOA leaflet is designed to encourage the disclosure of treatment errors. This is the only way to learn from mistakes and to increase patient safety, the brochure says.

Treatment errors are often hushed up
Errors happen in all areas and usually remain without serious consequences. However, giving a doctor too high a dose of strong medication or making a wrong diagnosis can have fatal consequences for the patient. Of the approximately 18 million patients admitted to German hospitals each year, around 18,000 die from treatment errors. That resulted in a scientific investigation. The number is a so-called low estimate. Experts assume a much higher number of unreported cases. Because often the clinic staff conceals his mistakes. This is confirmed by a study by the University of Bremen, which carried out a survey of carers in hospitals. Thus, 85 percent said that significantly less than half of all errors were reported in their facility. Who likes to admit that he has put a patient in danger or is even responsible for his death? In addition, many clinicians may fear damage to their hospital's reputation, and thus do not want to be notified of any mistakes that would force them to act. In addition, there is often agreement among physicians and nurses not to put anyone on the pillory. After all, everyone is overburdened by the need for care, overtime and shift work. Added to this is the fear of the consequences if a treatment error becomes known.

Brochure advises openness to treatment errors
To increase patient safety, the AOK has a new booklet titled „Every mistake is an opportunity ", in which former caregivers, who are now working in higher positions, talk about their mistakes in order to encourage doctors and caregivers to give treatment errors, so that they can avoid the mistake in the future The disinfection containers, which have meanwhile been installed everywhere in the hospital, have significantly reduced the number of hospital infections, but previously the errors had to be detected.

A cover-up error „Burdens the personality and forfeits the unique chance to protect other patients from repeating the mistake ", writes the health insurance in their brochure. „You can not avoid mistakes completely or even ban them, you can only learn from them. "

„It's brave to talk openly about mistakes, because that is the only way to learn from them. And it is also an elementary contribution to patient safety“, explains Jürgen Graalmann, CEO of the AOK-Bundesverband. „He who admits mistakes shows responsibility and deserves respect.“ It's not about asking „Who was to blame“ but rather „What was to blame“, it says in a statement of the health insurance. „Being open about mistakes is above all a cultural change“, reports Kai Kolpatzik, Head of the Department of Prevention in the AOK Federal Association. This change of perspective is the real challenge.

Protect patients from treatment errors
In conversation with the newspaper „The world“ Hardy Müller, honorary managing director of the action group patient safety in Hamburg, reports of its experiences. About the AOK brochure, which was created in cooperation with the association, says Müller: „This is a confession that mistakes always happen and that you should talk about them and not be pilloried. "It's not about identifying a culprit, but to put an end to the cause of the problem in the future to protect the patient Most treatment errors can be avoided, instead of investing time and money in innovations, Müller advocates safer use of existing treatment methods.

Legislators took action in February 2013, creating the conditions for a more open culture of error with the introduction of the Patients' Rights Act. According to this, the error reporting systems in hospitals must not be used for police or prosecutorial investigations. An exception, however, are grossly negligent or criminal acts. In this way, a drunken doctor, who undergoes a treatment error, punishable. However, the hospital staff is generally relieved and encouraged to be more open in dealing with errors. „The law relieves the employees, because it was made clear that an error message should not actually be used against one, "explains Müller. „An open handling of errors still has to be practiced. "In many clinics, there is still a great deal of silence about treatment errors.

Müller also sees the state in duty to do more. For example, there is only one institute for patient safety in Germany, whose employees scientifically analyze treatment errors and their avoidance. „To err is human, but not to invest in patient safety is deadly, "warns Müller.