An opinion piece by Danielle Ofri, an associate professor at New York University School of Medicine caused quite a bit of debate on the New York Times website recently. In the article, the author talks about her personal experience in the emergency department. A particularly hectic day caused her to fail to identify an intracranial bleed in an elderly patient. The author makes a very compelling argument for paying more attention to practitioners’ near misses by creating a medical culture that is less punitive and encourages people to come forward – for we can only prevent errors we know about.
Many commenters have applauded Dr. Ofri for taking a “long overdue” stance and for her “candour”. Other contributors drew comparisons to other industries such as aviation. Commenter “DesertSage” noted that “the Aviation Safety Reporting System (ASRS) allows for sharing information in a way that protects the pilots from reprisals by their airlines’ management. Could this be a model for hospitals?”
In a nursing professional group on LinkedIn, discussion contributors argued that a cultural change is unlikely to occur unless the legal framework is changes to protect doctors and nurses to talk more openly about their near miss experiences.
While the example in the article – and indeed most examples in the comment section – is specific to the US, we would be interest to hear your thoughts about the situation in Australia. The Australian Patient Safety Foundation is committed to create a culture of learning from patient safety incidents. Yet, is this enough to achieve a cultural change to address near misses in the emergency department? What role do leaders in hospitals have to play when it comes to dealing with near miss events? Do you have any suggestion on how to address this issue? Share your thoughts in the comment section.