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A Road Less Traveled: A German Error Reporting and Learning Solution for General Practitioners

JFZ is an open reporting system that allows anonymous reporting from anyone who works in a general practice setting, including medical assistants and office staff. 

Most of the discussion surrounding the implementation of error reporting and learning systems is focused on hospitals and surgical centers, but Germany’s first error reporting and learning system was designed for general practitioners.

Why the focus on hospitals?

There is some evidence that medical error frequency increases for both hospital-based physicians and physicians practicing in hospital-based disciplines. According to the Robert Koch Institute’s (“RKI”) 2001 Federal Health Report concerning medical errors in Germany, errors in the “cutting subjects” (surgery, gynecology, and orthopedics) were more frequent than errors in “conservative subjects” (internal medicine, dermatology, pediatrics, etc.). The report warns that these results may be misleading, because injuries caused by errors in the surgical disciplines are more easily recognized by patients and physicians, and therefore, more likely to be reported. For example, patients and physicians are more likely to detect surgical injuries such as birth defects, bone healing disorders, and unstable endoprosthesis, than they are to detect injuries caused by errors in conservative disciplines, such as poor adjustment of diabetes and poor management of mental disorders. [1]

The report also found that hospital practitioners are more often accused of medical malpractice than their clinical counterparts. While it is true that patients are more critical of hospital physicians than they are of their family physicians, with whom they have a history and personal relationship, it is also true that hospitals are more likely to suffer systemic error-causing deficiencies. Whether the statistics of reported errors accurately depict the rate of actual errors, it remains that physicians who practice in hospitals bear the brunt of error allegations, and from a risk-management standpoint, focusing on error prevention in hospitals is a sure way to decrease the number of malpractice claims.[2]

Why should we also focus on general practitioners?

If the true goal is error prevention, then prevention work involves more than preventing only the errors that lead to malpractice claims, but also errors that go undetected. Although they are less reported, RKI found that once reported, errors in the “conservative subjects” are more likely to be confirmed by medical review boards and courts. Similarly, the smaller the healthcare organization, the more likely a reported error is to be confirmed.[3] Smaller practice environments also typically do not offer the peer review and learning opportunities available to hospital physicians.[4]

Jeder-Fehler-Zaehlt. Every Error Counts.

In 2005, the Institute for General Practice and the University of Frankfurt am Main developed Jeder-Fehler-Zaehlt (JFZ), a web-based voluntary anonymous incident reporting system for general practitioners in German-speaking countries.[5]

JFZ is an open reporting system that allows anonymous reporting from anyone who works in a general practice setting, including medical assistants and office staff. Once the report is submitted, it is reviewed for anonymity, then published on the website for comments and analysis by the Institute, outside experts, and other users of the website. In order to completely protect patients, reporters, and other persons involved, legal experts recommended an anonymous, rather than confidential, system.[6]

Every month the Institute publishes an “error of the month,” which highlights an error that is frequent, common, or easily learned from. Below is an example of an error of the month.

In addition to highlighting errors of the month, the Institute also provides detailed analysis for selected cases, in which they discuss contributing factors, missing or existing safety barriers, and possible ways in which similar events could be prevented. Other features of the user-friendly website allow general practitioners and their staff to search the reporting database based on type of error, diagnosis, drugs involved, and contributing factors; access tips for avoiding errors; and find literature relevant to error prevention in general practice.[8]

Many roads lead to prevention. Let’s consider one less traveled.

Not only does Germany’s Jeder-Fehler-Zaehlt help prevent errors in general practice, it also promotes error safety culture in all healthcare settings by providing a safe space for open discussion of mistakes. The comment space provides positive feedback for those who are willing to report and ignites a professional, respectful discussion of errors with a “this could have happened to me” attitude. This positive culture is in stark contrast to the blame culture prevalent in medical malpractice litigation, in which physicians are defensive and healthcare providers often turn against one another.

Am I condemning medical malpractice litigation? Absolutely not. I’m a litigation attorney after all, and I recognize that litigation is one path for generating societal change, including in the healthcare industry. What I am saying is that there are other concurrent paths available to promote medical error prevention, and that any person truly committed to reducing medical errors should consider all paths that may lead to prevention, even ones less traveled.

[1] Robert-Koch-Institut, Statistisches Bundesamt (Hrsg.): Gesundheitsberichterstattung des Bundes, Medizinische Behandlungsfehler in Deutschland, Heft 4/01, 2001 (accessed on January 20, 2017)

[2] Id.

[3] Id.

[4] B. Hoffman, M. Beyer et al. “Every error counts”: a web-based incident reporting and learning system for general practice. Qual. Saf. Health Care 2008;17;307-312.

[5] Id.

[6] (accessed on January 20, 2017)

[7] The German text has been translated to English.

[8] (accessed on January 20, 2017)