Are There a Lot of Medical Errors That Are Not Reported?

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Huge numbers of medical errors that are not reported. The part of problem is that the reporting systems that we have are in the most part voluntary and it might seem logical when you just make them mandatory. There is also a problem in that there are so many errors in the system in the given day that if we report every single error, and I'm not talking about, we operate on wrong patients or there were fatal medication, those do get reported.

It's mandatory they get reported. They are analysed deeply. I think those systems are actually working okay. But I'm about the little kind of day to day glitches, the more equivalent of you forgetting where you left your car keys, that an error, it may of course any harm, but there is something went wrong, we might want to know about and fix it, but if all of those got to reported, any individual hospital in the country will probably have 50 to 100 thousand reports in a year, so the analogy you get here when the safety field launch about 10 or 15 years ago, a lot of the analogies were to aviation, how can aviation be so breathtakingly safe, how can medicine be so unsafe, what can be learnt.

It's turned up that a lot of aviation have been really very helpful, checklist, standardizing the cockpit, simulation training, thinking about your work as a system, those sort of things have been really important. I think we have embraced them and began to learn how to do that work.

The reporting analogy actually does not work very well because the aviation system does have a mandatory reporting system. When you see something that is unsafe, if you had a near miss, you must report it to that system. They do a very deep analysis of what went wrong and if you don't report it and someone finds out later that it happened, you'll get fired, whereas if you do report it, it's many ways you get out of jail free card.

There's a national reporting system. It's actually run by NASA not by the FAA. They wanted it run by a separate agency. So we looked at that and we said what a great idea. We should encourage people to report everything. It turns out that the aviation reporting system in a year gets about 35,000 reports across the entire US commercial aviation fleet.

My one hospital could easily get 50,000-100,000 reports. There are 6000 and hospitals in the United States. Now part of the difference there is aviation is so unbelievably safe that the glitches don't happen very often and medicine is not, and glitches are extraordinarily commonplace.

The second is aviation doesn't need a reporting system for the hits. It has ABC news and CNN and the internet now, so if you think about the scale and the scope of our problem, although it seems logical to say we just need more reporting, that would fix it. I don't think that's the answer.

It would overwhelm us. We already know how many problems there are, we already know many of the targets that we need to fix, and I'm just at this point not convinced that more reporting is going to get us anywhere.