A ‘‘Red Cover Report’’ Will Save Lives

Hospitals and other healthcare organizations simply do not have the ethos and/or systems to aggressively share accident/incident/near-miss information. The current practice of allowing sealed records in malpractice cases guarantees that life-saving safety information will be forever denied to the profession. The Red Cover Report could be certified as an avenue of immediate safety communication. No disciplined, systemic approach (including the so-called root cause analysis) has yet been applied in American health care to present accidents and near-missesV stripped of nonpertinent identifying information about hospital, patients, or practitioners that can harvest the clinically critical knowledge available for prevention purposes. Furthermore, although the institution of the root cause analysis is widely used as an investigative protocol, it has several major flaws: a clear lack of national uniformity in discussion and presentation, heavily curtailed availability outside a specific institution, no translation of the lessons learned to a wider clinical audience, and an incorrect focus on a single

cause versus the critical reality that there is never just one cause to a medical accident, incident, or misadventure.

Although The Joint Commission serves a terrific role in health care, its Sentinel Event database is extremely small compared with the actual incidence of events in America. We need more. The great benefit of an NTSB approach is that it would not require analysis of every healthcare accident; it could address those events that could have the greatest value to the nation. Critics of health care argue that many hospitals maintain risk-management strategies that are really ‘‘malpractice claims management strategies,’’ focused on sequestering information, gagging survivors and surviving families through awards, and burying mistakes that prevent learning moments. A ‘‘Red Cover Report’’ will move us closer to prevention and give meaning to the lives that are lost, which is what most families seek through their grief.

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