Most medical professionals who provide radiation therapy rarely report near-misses or errors, not because of the amount of time it takes or the complications of using the on-line error reporting systems, but rather, fear of getting into trouble and embarrassment. In fact a recent survey by Johns Hopkins places the number at 90% of providers who witness near-misses or errors and never report them, because they are embarrassed and don't want to get their co-workers or themselves in trouble. See John Hopkins Survey titled, "Survey Reveals Reasons Doctors Avoid Online Error-Reporting Tools."
Investigators who emailed anonymous surveys to physicians, nurses, radiation physicists and radiation specialists at John Hopkins, North Shore Long Island Jewish Health Systems in New York, Washington University in St. Louis, Missouri, and the University of Miami, asked questions about near misses and errors in delivering radio therapy in order to better address problems associated with these procedures and how to improve the quality.
The results show that the complexity of the software is not the problem, nor the amount of time it takes to file the reports, but rather the personnel want to avoid embarrassment to themselves or their co-workers, and avoid getting anyone into trouble, when mistakes are made or narrowly avoided. This survey presents valuable feedback that could relate to other medical areas as well, and most importantly can help medical facilities set standards that encourage the reporting of errors and near-misses, rather than hide them. If the systems are used not to punish the medical professionals who report mistakes but rather to improve the process, perhaps the safety record can be improved and everyone will benefit, from the patients, to the medical staff, to the medical facilities, to the insurance companies. Johns Hopkins radiation oncology resident Kendra Harris, M.D. remarked, "It is important to understand the specific reasons why fewer physicians participate in these reporting systems so that hospitals can work to close this gap. Reporting is not an end in itself, it helps identify potential hazards, and each member of the health care team brings a perspective that can help make patients safer."
Most of the respondents in the survey said they would be interested in participating in a national reporting system for radiotherapy near-misses and errors. A national system would be able to collect all the shared data and look for trends, which could help medical professionals improve safety standards.
