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The readers’ responses underline the relevance of patient safety and the need for quick as well as more detailed information on the subject. We thank our correspondents for their comments and additions, which bring to attention important studies and projects aiming to improve patient safety in Germany.

Professor Schaffartzik and attorney Neu note the omission of the arbitration boards’ Medical Error Reporting System (MERS) from the list of incident reporting systems. However, the arbitration boards’ MERS is a registry of malpractice claims, not an incident reporting system in the actual sense. As shown in our article, such reporting systems receive their reports from the service providers themselves (staff at hospitals, practices, or nursing institutions). They include near-misses, errors, critical events, and harm events. By contrast, the MERS includes cases of suspected or actual treatment errors that resulted in actual harm to the patient in every case (the very reason why the patient involved the arbitration board). Such cases are evaluated by the arbitration boards’ staff on the basis of the available files (for example, expert opinions) and then entered into the MERS database, which, consequently, enables different analyses to incident reporting systems.

Incident reporting systems use primarily information from insiders within the organization in the healthcare system that is not documented; a treatment error registry analyses data that are documented in patients’ files. A registry such as the MERS does offer an additional window into the system (1)—albeit one with a different perspective—and thus enables important insights into adverse events and their causes.

Dr Tönneßen thankfully mentions the German Medical Association’s CME concept “patient safety” (2) and introduces the exemplary activities embarked on at Magdeburg university medical center and medical faculty. We wish to mention a new working group focusing on education and training within the German Coalition for Patient Safety, which will dedicate itself entirely to this subject while keeping a broad focus on all healthcare and allied professions (3).

Professor Engelhardt et al mention the exemplary adverse event prevention project at Freiburg University Medical Center and show just how manifold patient safety activities in Germany are.

Professor Müller-Oerlinghausen and Dr Aly complain about the lack of detail about the action plan drug safety. The federal health ministry’s action plan did not find its way into our review article because of our particular focus on the causes and contributing factors of medical errors and the necessary restriction on naming only a few measures to prevent errors.

Professor Hanisch comments that the article does not focus in a concrete manner on the known causes of human error. He explicitly names fatigue and stress as the factors that the WHO considers as having the greatest influence on error proneness. We wholeheartedly agree that these factors are important in terms of negative outcomes. Fatigue, stress, and time pressures have a potentially devastating effect on patient safety in hospitals and practices, all the more if occurring in problematic institutions in terms of organization, communication, education, and supervision. In view of the current working conditions at some hospitals that we are aware of, we do not think that checklists can be implemented without a higher expenditure in terms of time (4), but we wish to emphasize their importance (5), which is also due to the fact that clinical actions are transparent for all parties involved and is communicated as such (6).

Staff shortages, however, do not fundamentally prevent all attempts to achieve greater patient safety. They may support the development of innovative ideas and concepts and increase patient safety. This should not be done at the expense of the staff, however. The resources that are necessary to improve patient safety should unfailingly be applied for and should be granted.

In the 10 years since “To err is human,” Germany has introduced various measures to improve patient safety. This review article and resulting correspondence have shown that we are taking the right steps towards a learning healthcare system, to learning organizations that will tackle the question: what are we actually doing, and what positive and negative effects does it have?

DOI: 10.3238/arztebl.2010.0559

Dr. med. Barbara Hoffmann, MPH

Institut für Allgemeinmedizin

Johann Wolfgang Goethe-Universität

Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany

Hoffmann@allgemeinmedizin.uni-frankfurt.de

Dr. med. Julia Rohe, MPH

Ärztliches Zentrum für Qualität in der Medizin (ÄZQ)

Gemeinsames Institut von BÄK und KBV

TiergartenTower

Strasse des 17. Juni 106–108, 10623 Berlin, Germany

rohe@azq.de

Conflict of interest statement
The authors declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

1.
Vincent C: Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2004; 13: 242. MEDLINE
2.
Fortbildungskonzept „Patientensicherheit“ (2009): Texte und Materialien der Bundes­ärzte­kammer zur Fortbildung und Weiterbildung Band 25.
4.
Baberg HT, Burgard G: Mit Checklisten sicher kommunizieren. Management und Krankenhaus 2009; 28: 7.
5.
Aktionsbündnis Patientensicherheit e.V. (2010) Stellungsnahme zu Checklisten in der Gesundheitsversorgung
6.
Die World Alliance of Patient Safety der WHO bietet neben der Surgery Safety Checklist auf ihrer website auch Videos an, die zeigen, wie man die Checkliste einsetzen soll und auch, wie nicht.
7.
Hoffmann B, Rohe J: Patient safety and error management — What causes adverse events and how can they be prevented? [Patientensicherheit und Fehlermanagement: Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung]. Dtsch Arztebl Int 2010; 107(6): 92–9. VOLLTEXT
1.Vincent C: Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2004; 13: 242. MEDLINE
2.Fortbildungskonzept „Patientensicherheit“ (2009): Texte und Materialien der Bundes­ärzte­kammer zur Fortbildung und Weiterbildung Band 25.
3.Aktionsbündnis Patientensicherheit – AG Bildung und Training
4.Baberg HT, Burgard G: Mit Checklisten sicher kommunizieren. Management und Krankenhaus 2009; 28: 7.
5.Aktionsbündnis Patientensicherheit e.V. (2010) Stellungsnahme zu Checklisten in der Gesundheitsversorgung
6.Die World Alliance of Patient Safety der WHO bietet neben der Surgery Safety Checklist auf ihrer website auch Videos an, die zeigen, wie man die Checkliste einsetzen soll und auch, wie nicht.
7.Hoffmann B, Rohe J: Patient safety and error management — What causes adverse events and how can they be prevented? [Patientensicherheit und Fehlermanagement: Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung]. Dtsch Arztebl Int 2010; 107(6): 92–9. VOLLTEXT