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Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières
Leslie Shanks1, Karla Bil1, Jena Fernhout1
1Médecins Sans Frontières-Operational Centre Amsterdam, Plantage Middenlaan 14, PO Box 10014, 1001 EA Amsterdam, The Netherlands.
Objective:
To analyse the results from the first 3 years of implementation of a medical error reporting system in Médecins Sans Frontières-Operational Centre Amsterdam (MSF) programs.
Methodology:
A medical error reporting policy was developed with input from frontline workers and introduced to the organisation in June 2010. The definition of medical error used was "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." All confirmed error reports were entered into a database without the use of personal identifiers.
Results:
179 errors were reported from 38 projects in 18 countries over the period of June 2010 to May 2013. The rate of reporting was 31, 42, and 106 incidents/year for reporting year 1, 2 and 3 respectively. The majority of errors were categorized as dispensing errors (62 cases or 34.6%), errors or delays in diagnosis (24 cases or 13.4%) and inappropriate treatment (19 cases or 10.6%). The impact of the error was categorized as no harm (58, 32.4%), harm (70, 39.1%), death (42, 23.5%) and unknown in 9 (5.0%) reports. Disclosure to the patient took place in 34 cases (19.0%), did not take place in 46 (25.7%), was not applicable for 5 (2.8%) cases and not reported for 94 (52.5%). Remedial actions introduced at headquarters level included guideline revisions and changes to medical supply procedures. At field level improvements included increased training and supervision, adjustments in staffing levels, and adaptations to the organization of the pharmacy.
Conclusion:
It was feasible to implement a voluntary reporting system for medical errors despite the complex contexts in which MSF intervenes. The reporting policy led to system changes that improved patient safety and accountability to patients. Challenges remain in achieving widespread acceptance of the policy as evidenced by the low reporting and disclosure rates.
Insights
A voluntary medical error reporting system was successfully implemented in Médecins Sans Frontières programs, leading to improved patient safety. Challenges in reporting and disclosure rates persist despite system changes.
Area of Science:
- Healthcare Management
- Patient Safety
- Medical Error Analysis
Background:
- Médecins Sans Frontières (MSF) implemented a medical error reporting system in 2010.
- The system aimed to capture and analyze medical errors in complex operational contexts.
Purpose of the Study:
- To analyze the results of the first three years of a medical error reporting system implementation.
- To assess the feasibility and impact of the system on patient safety and accountability.
Main Methods:
- A voluntary medical error reporting policy was developed with frontline worker input.
- 179 confirmed error reports were collected from June 2010 to May 2013.
- Errors were categorized by type, impact, and patient disclosure.
Main Results:
- Reporting rates increased annually, with 179 errors reported over three years across 18 countries.
- Dispensing errors, diagnostic errors, and inappropriate treatments were the most common error types.
- Over 60% of errors resulted in harm or death, with patient disclosure rates remaining low.
Conclusions:
- Implementing a voluntary medical error reporting system is feasible in challenging humanitarian settings.
- The reporting system facilitated system changes that enhanced patient safety and accountability.
- Low reporting and disclosure rates indicate ongoing challenges in policy acceptance and implementation.