It's a simple concept: Study your mistakes and learn from them.
But researchers say it has been slow to catch on at hospitals, which tend to focus on blaming an employee when a patient dies or is injured, rather than examining their system as a whole.
Jacksonville physician Robert Wears has launched an effort to get Florida hospitals and agencies to follow Massachusetts and Texas in creating a coalition to study why mistakes happen and how to prevent them.
Hospital errors occur so regularly that researchers and even the hospital industry now say it isn't a matter of incompetent workers but of a need for more quality controls.
"In times past, when anything bad happened, we'd look to find the 'bad apple,'" said Susie White, the Florida Hospital Association's vice president for quality management. "[But] people don't come in figuring out how they can screw up their workday."
The association hasn't heard Wears' pitch yet, but White said it is willing to listen. The association held a conference in Florida last year on how to catch and prevent errors. The conference included the National Patient Safety Foundation, a group started by the American Hospital Association.
Wears began pitching his idea last week to hospital officials in Jacksonville, based on the Massachusetts Coalition for the Prevention of Medical Errors. Doctors started that group last year, following publicized cases of serious medical errors in that state and elsewhere. Probably the most visible case in Massachusetts was a Boston Globe health columnist's death from a chemotherapy overdose.
Florida needs a coalition to update hospitals on what they can do to catch errors before they harm patients, said Wears, a Shands Jacksonville emergency room physician and University of Florida professor.
The public tends to hear about isolated cases in the media, such as the Tampa surgeon who amputated the wrong foot in 1995, or the 1998 death of Hilliard resident Arthur Holton Jr., a surgery patient at Shands Jacksonville who police concluded died from an accidental morphine overdose.
But more studies are showing errors are commonplace, since a landmark 1991 study of New York hospitals concluded about one of every 200 patients died because of a medical error. That study's author, Lucian Leape, a Harvard School of Public Health professor, helped start the Massachusetts coalition.
In the September issue of the Annals of Emergency Medicine, Leape and Wears co-authored an editorial citing another study's conclusion that 4 percent of all hospitalized patients die, are disabled, or have a prolonged hospital stay --- nd more than 70 percent of those cases are preventable.
"The magnitude of this problem is overwhelming," Leape and Wears wrote.
"If these results are generalized, then more than 1 million patients each year are injured in preventable medical accidents, and approximately 100,000 die, which is twice the annual highway death rate."
FEAR OF LAWSUITS
Studying errors is risky. Hospitals fear the information they gather could be used in lawsuits. And doctors, nurses and others are trained that they shouldn't have to rely on help from others, Wears said. When they make an error, they are so ashamed they won't admit it.
"From a society's point of view, as a result, no one can learn from the error," Wears said.
Hilary Mathews, associate administrator for St. Luke's Hospital, said her organization would be interested in joining a coalition.
"If we can improve upon our systems to prevent errors? Absolutely," she said.
William McLear, a physician and senior vice president for medical affairs for Baptist St. Vincent's Health System, said he strongly supports the creation of a coalition like Massachusetts', but said it needs broad support from hospitals, doctors, pharmacists, nurses and others in health care. …