When you choose a health care facility, the executive director of the Nebraska Coalition for Patient Safety says you should add one important query to your list of questions: “Do you self-report adverse events?”
And if the answer is “no,” Ann McGowan said, maybe you should get your knee replacement — or whatever it may be — somewhere else.
About the NCPS
NCPS is an independent, nonprofit, federally-designated patient safety organization (PSO), founded by several key state health care associations and headquartered in the UNMC School of Allied Health Professions.
It encourages, assists and collaborates in the self-reporting of medical errors and patient-safety events by health care organizations across the state. The reports are then studied, and de-identified and shared across NCPS membership. The hope is avoid repeats of similar incidents.
“By sharing this information with others, hospitals can learn to prevent errors before they happen,” said Stephen Smith, M.D., NCPS president and chief medical officer at UNMC’s hospital partner, The Nebraska Medical Center.
Progress report
NCPS has trained more than 250 professionals from 59 health care organizations in the use of root-cause analysis — a tool to analyze and learn from adverse events.
Half of Nebraska’s hospitals have joined the coalition — but half have not. It’s tough to crack the culture of keeping our mistakes to ourselves, said Darwin Brown, assistant professor in UNMC’s physician assistant education program, who serves as NCPS treasurer.
Learning from the truth
But those happen, whether the public hears about them or not. A 2008 U.S. Department of Health and Human Services report found that 13.5 percent of Medicare beneficiaries surveyed experienced a serious adverse event during their hospital stays. An additional 13.5 percent experienced smaller events which resulted in temporary harm.
If we hear of an incident, we may be less apt to use that hospital.
“But I tend to think the opposite,” McGowan said. “It means they’re engaged. They know what’s going on.”
Mistakes happened, but they don’t need to be repeated
We all make mistakes — even health care organizations.
There’s only one way to find out if a health care organization is learning from its mistakes, McGowan said: Ask.
Visit www.nepatientsafety.org or call McGowan at 402-559-8421 for more information.