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Research review sheds light on error reporting

Respiratory Care Weekly, August 9, 2006

Two University of Iowa studies examined 118 different factors in error reporting, according to reports in the April Joint Commission Journal on Quality and Patient Safety and the May 31 Journal of General Internal Medicine. In looking at previously published papers on error reporting, researchers found the following two themes:

* The person reporting the error feels personally responsible for harming a patient, even if the error was caused by a general practice or a fault in the hospital's system

* People get frustrated at hospital error-reporting systems that provide little or no feedback

"Often an error is not directly an individual person's fault, but a system-based problem," Lauris Kaldjian, MD, PhD, lead researcher said. "Some doctors said they felt like they're sending a message into a black hole. This can make them less likely to take time out of a busy schedule to report an error. So, feedback is important."

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