Working in an emergency department for 10 years means forming tight bonds with colleagues, said LaDonna Jenkins, a licensed practical nurse at the Augusta Department of Veterans Affairs Medical Centers. And even though she has seen only one medication error in that time, she knows witnessing an incident also means being put in a tight spot.
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"In a close-knit group like this, you don't want to cause problems," Ms. Jenkins said. "Yet someone needs to know."
That's one reason the VA is going with a confidential nationwide program called the Patient Safety Reporting System, which covers not only mistakes, but also close calls. Run by a division of the National Aeronautics and Space Administration, it is similar to one NASA has run for 27 years for the Federal Aviation Administration, said Richard Wheat, a medical safety analyst with the program.
The FAA program grew out of an airplane crash that resulted from confusing instructions from an air traffic controller, which others had noted but had not reported, Dr. Wheat said.
"They wouldn't report internally to the FAA because they were afraid they'd lose their jobs," he said.
Overcoming the fear of retaliation is something hospitals across Georgia are working on, said Vi Naylor, the executive vice president of the Georgia Hospital Association.
"Part of that is encouraging people to report when there is an error," she said.
Apparently it is working - hospitals said error reports are up threefold in recent years, not because of an increase in errors, but because of a greater willingness to speak up, Ms. Naylor said.
The hospital association also has an anonymous system for members to report problems so that the association can spot and report back on trends or potential pitfalls.
The VA has already implemented several new systems to cut down on errors, such as computerized medication carts that link to bar-coded arm bands issued to patients so that the right medication gets to the right patient, officials said. And the VA is learning from incidents, said Kathy Frazier, patient safety coordinator at the Augusta VA.
"There's been different glazing put on windows in psychiatric facilities," after incidents in which patients jumped through them, she said.
Having another outlet to turn to if something happens does add some peace of mind, Ms. Jenkins said.
"Knowing this is available helps."
Reach Tom Corwin at (706) 823-3213 or tomc@augustachronicle.com.
