Intersystem Medical Error Discovery in Otolaryngology-Head and Neck Surgery

Area of Science:

• Medical error analysis
• Patient safety research
• Otolaryngology quality improvement

Background:

• Intersystem medical error discovery (IMED) involves identifying errors occurring outside one's facility.
• Limited explicit guidance exists for IMED, despite its impact on patient safety and care quality.
• IMED is a significant concern in otolaryngology due to complex conditions and subspecialization.

Purpose of the Study:

• To explore otolaryngologists' perceptions and practices regarding feedback and reporting of IMED.
• To identify strategies for preventing or responding to intersystem medical errors.

Main Methods:

• Qualitative study using semistructured virtual interviews.
• 24 otolaryngologists with patient safety and quality improvement expertise were interviewed.
• Purposive sampling ensured diversity in subspecialty, career stage, geography, practice context, and demographics.

Main Results:

• Barriers to IMED feedback/reporting included logistical, psychosocial, and structural factors.
• Facilitators for feedback/reporting involved severe, egregious, or repetitive errors, and existing relationships.
• Most participants felt IMED was inadequately addressed, proposing solutions like feedback training and standardized guidelines.

Conclusions:

• The lack of standardized processes and resources hinders effective IMED responses.
• Opportunities exist to improve clinical practice and health system policies for IMED.
• Enhanced feedback and reporting mechanisms are crucial for patient safety across healthcare systems.