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Detecting and reporting medical errors: why the dilemma?

Errors in medicine are a major cause of harm to patients. Though there is little controversy among clinicians about the importance of accurate and reliable clinical data and the imperative of correct diagnosis, that commitment to exactitude dissolves when errors happen. Then, clinicians and managers may behave in a way that limits investigation. We often use the subjectivity and complexity of medicine to rationalise and justify error.

Many factors explain this reluctance to investigate and to accept error. If we are to design effective systems to prevent errors from affecting patients, we must understand these factors. The following case study illustrates the concerns, fears, and practical problems that we faced in conducting an evaluation of misinterpreted prostate biopsies.

#### Summary points

Detection and prevention of errors are obvious goals for any organisation

In reality, however, medicine's approach to error has been limited and inadequate

Motivational factors, both real and perceived, that influence how errors in medicine are handled must be identified, discussed, and changed if the “patient safety movement” isto succeed

Our experience with misread prostate biopsies illustrates the concerns, fears, and practical problems encountered when dealing with the discovery of medical errors

In February 1999 a urologist at the Sturdy Memorial Hospital in Attleboro, Massachusetts, requested a retrospective review of a 1996 biopsy result because of the patient's clinical course and the results of a biopsy in 1999. The review revealed that the 1996 report was incorrect. The urologist and pathologist (neither of whom was responsible for the 1996 reading) implemented appropriate management for the affected patient.

When they discovered a second misread prostate biopsy from the same period the urologist and pathologist became concerned that the frequency of these errors was higher than “expected.” Fears about malpractice suits and damaged reputations emerged. The potential ofa bigger problem meant risk to more …