Voluntary electronic reporting of medical errors and adverse events
- Catherine E. MilchAffiliated withDepartment of Medicine and the Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center
- , Deeb N. SalemAffiliated withDepartment of Medicine, Division of Cardiology, Tufts-New England Medical Center
- , Stephen G. PaukerAffiliated withDepartment of Medicine, Division of Clinical Decision Making, Tufts-New England Medical Center
- , Thomas G. LundquistAffiliated withDepartment of Medicine, Division of Clinical Decision Making, Tufts-New England Medical CenterI-trax Health Management SolutionsDepartment of Pediatrics, Nemours Children’s HospitalBryn Mawr Hospital
- , Sanjaya KumarAffiliated withQuantros Inc.
- , Jack ChenAffiliated withQuantros Inc.
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OBJECTIVE: To describe the rate and types of events reported in acute care hospitals using an electronic error reporting system (e-ERS).
DESIGN: Descriptive study of reported events using the same e-ERS between January 1, 2001 and September 30, 2003.
SETTING: Twenty-six acute care nonfederal hospitals throughout the U.S. that voluntarily implemented a web-based e-ERS for at least 3 months.
PARTICIPANTS: Hospital employees and staff.
INTERVENTION: A secure, standardized, commercially available web-based reporting system.
RESULTS: Median duration of e-ERS use was 21 months (range 3 to 33 months). A total of 92,547 reports were obtained during 2,547,154 patient-days. Reporting rates varied widely across hospitals (9 to 95 reports per 1,000 inpatient-days; median =35). Registered nurses provided nearly half of the reports; physicians contributed less than 2%. Thirty-four percent of reports were classified as nonmedication-related clinical events, 33% as medication/infusion related, 13% were falls, 13% as administrative, and 6% other. Among 80% of reports that identified level of impact, 53% were events that reached a patient (“patient events”), 13% were near misses that did not reach the patient, and 14% were hospital environment problems. Among 49,341 patient events, 67% caused no harm, 32% temporary harm, 0.8% life threatening or permanent harm, and 0.4% contributed to patient deaths.
CONCLUSIONS: An e-ERS provides an accessible venue for reporting medical errors, adverse events, and near misses. The wide variation in reporting rates among hospitals, and very low reporting rates by physicians, requires investigation.
Key wordsmedical errors adverse events error reporting systems electronic reporting
- Voluntary electronic reporting of medical errors and adverse events
Journal of General Internal Medicine
Volume 21, Issue 2 , pp 165-170
- Cover Date
- Print ISSN
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- medical errors
- adverse events
- error reporting systems
- electronic reporting
- Industry Sectors
- Author Affiliations
- 1. Department of Medicine and the Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, MA, USA
- 2. Department of Medicine, Division of Cardiology, Tufts-New England Medical Center, Boston, MA, USA
- 3. Department of Medicine, Division of Clinical Decision Making, Tufts-New England Medical Center, Boston, MA, USA
- 4. I-trax Health Management Solutions, Philadelphia, PA, USA
- 5. Department of Pediatrics, Nemours Children’s Hospital, Jacksonville, FL, USA
- 6. Bryn Mawr Hospital, Bryn Mawr, PA, USA
- 7. Quantros Inc., Milpitas, CZ, USA