Peter J. Pronovost, MD, PhD
The Johns Hopkins University School of Medicine
Baltimore, Maryland, USA

Christine G. Holzmueller, BLA
The Johns Hopkins University School of Medicine
Baltimore, Maryland, USA

Sandra P. Bagwell, MD, FCCM
Maine Medical Center
Portland, Maine, USA

The duty of reporting incidents has been an integral part of healthcare administration for decades.

Traditionally, reports are gathered by nurse managers or other unit leaders and shipped to risk management or quality assurance for investigation and appropriate action. Typically, the action targets an individual who is judged and disciplined.

“To Err is Human,”(1) helped healthcare turn the corner and move away from blaming a person. This Institute of Medicine (IOM) report and other researchers2-4 led the Intensive Care Unit Safety Reporting System (ICUSRS) to look at how care is organized (system factors) and how it may contribute to harm. It showed that healthcare providers are heroes, not enemies. In fact, nurses, doctors, pharmacists, and others work hard every day to limit and prevent broken systems from harming patients. In the first year of reporting to the Web-based error reporting system, the ICUSRS staff found that providers limited harm in 57% of incidents (488 of 854) and perceived that providers could have prevented 49% of incidents (414 of 854).

To improve safety and reduce errors, we must standardize processes of care. Healthcare providers reduce defects through their use of double-checking and independent redundancy. Double-checking can be done by two people at the same time or by one person who returns to recheck his or her work. One example of the success of double-checking involved two nurses who noticed before administering a unit of fresh frozen plasma to a male patient that the number on the bag was different than the number on the paper attached to the plasma bag. They returned the unit of blood to the blood bank. Another institution participating in the ICUSRS implemented a double-check program in an adult and pediatric ICU and improved medication safety in both units.

Independent redundancy, while similar in nature to double-checking, is a different process. An independent redundancy involves two separate people checking independently of each other and then comparing their findings to see if they match. While double-checking is efficient, independent redundancy is more effective in eliminating errors because it removes the bias engendered when two people simultaneously share the same conclusion. Indeed, the value of independent redundancy is that checks are truly independent. In the real world, however, double checking may be more feasible in many institutions since coordinating two individuals to separately perform checks could pose staffing challenges.

Another way to standardize processes of care is by bar coding. The Food and Drug Administration recently passed a requirement for bar code labeling of human drug and biologic products.5,6 This rule has the potential to reduce medication errors in that scanning adds a method of verifying right drug, dose, administration route, patient, and/or blood product.

While technology, such as bar coding, as a standardized process of care can help improve patient safety, it may also pose a new set of safety hazards. As such, healthcare must always rely on dedicated and qualified providers who work in complex medical systems to mitigate and prevent patient harm.