A physician-based voluntary reporting system for adverse events and medical errors

Area of Science:

• Patient Safety
• Medical Error Reporting
• Healthcare Quality Improvement

Background:

• Adverse events (AEs) and potential adverse events (PAEs) pose significant risks to patient safety in hospital settings.
• Effective identification and reporting systems are crucial for mitigating these risks and improving care.
• Current reporting mechanisms may have limitations in capturing the full spectrum of medical errors.

Purpose of the Study:

• To develop and evaluate a voluntary reporting method for identifying AEs and PAEs among medical inpatients.
• To assess the feasibility and acceptability of a physician-based reporting system.

Main Methods:

• Structured, confidential interviews were conducted by medical residents with their peers (interns) during work rounds.
• Interview topics included obstacles to care, patient injuries, extended hospitalizations, and medication-related problems.
• Event narratives were independently reviewed and corroborated with hospital incident reports and retrospective chart reviews.

Main Results:

• Over three months, 88 events were reported, with AEs affecting 0.5% and PAEs 4.9% of admissions.
• Delayed diagnoses and treatments were common PAEs (54%).
• Clinicians were identified as the primary responsible party (55%), followed by laboratory, radiology, and pharmacy personnel. Problematic processes included diagnosis, therapy, and service delivery issues.

Conclusions:

• A physician-based voluntary reporting system for medical errors is a feasible and acceptable method for front-line clinicians.
• This approach can enhance the identification of adverse events and potential adverse events in inpatient settings.
• The system offers a valuable tool for quality improvement initiatives in healthcare.