As perioperative nurses, it's important that we provide compassion and accurate information to allay the anxiety associated with surgery. We work in a profession where adverse events occur and outcomes can result in life-threatening situations. While the recent release of mandatory state adverse event reports brings this concern to the forefront, it also indicates that we can improve patient safety by reviewing quality of care information.
The reporting of adverse events stems from the Institute of Medicine's (IOM) publication, To Err is Human, Building a Safer Health System. The report called the healthcare system to action by estimating that 44,000 to 98,000 annual deaths occur from medical errors. The intention of the reporting system is to enhance quality of care by notifying health officials regarding events and determining system flaws that may have promoted the event.1
A commitment to transparency in healthcare is a significant part of this system. Because quality of care can vary from one facility to another, transparency allows providers to openly disclose facts about their pricing, performance, and background to the consumer. The intent is to supply information to the public so they can make informed healthcare choices based on outcomes. Part of the information upon which they can base their choices is included in the event reporting system.
Reporting systems are available to healthcare agencies through voluntary and mandatory reporting. While The Joint Commission encourages voluntary reporting, some states have committed to increasing patient safety through mandatory reporting efforts. As of 2006, nearly half of the United States had mandatory event reporting systems.2
Misleading reports
Despite the obvious merits of adverse event reporting, some states don't solicit or report any adverse events at all. While a state may mandate that adverse events and information need to be reported, the institution defines whether the event meets the standard. In many cases, this results in underreporting.
Also, results are often depicted as singular events that don't fit within the context of the organization. For instance, a recent article disclosed the number of retained foreign objects reported in one state. To the healthcare consumer, the report may generate alarm. However, it didn't denote the number of surgical procedures completed during the reporting time, if it represented an increase or a decrease from the previous year, and whether the standards defining adverse events remained the same or were redefined and made more rigorous based on results. Finally, the dual system of mandatory state reporting and voluntary Joint Commission reporting results in a disparity in the number of events reported by each organization, making results difficult to interpret.
A good decision
Despite these obstacles, improving patient safety and outcomes through evaluations of patient events has been shown to improve clinical patient safety and clinical outcomes. Furthermore, system changes that enhance the provision of quality care can only benefit our patients in the long run. By disclosing information in a manner that is helpful and easy to understand, we can help our patients interpret information and assist them in making good decisions regarding their healthcare.
Elizabeth M. Thompson, RN, MSN
Editor-in-Chief, Nursing Education Specialist, Mayo Clinic, Rochester, Minn.
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