Journal of General Internal Medicine

, Volume 21, Issue 2, pp 165–170

Voluntary electronic reporting of medical errors and adverse events

An analysis of 92,547 reports from 26 acute care hospitals
  • Catherine E. Milch
  • Deeb N. Salem
  • Stephen G. Pauker
  • Thomas G. Lundquist
  • Sanjaya Kumar
  • Jack Chen
Original Articles

DOI: 10.1007/s11606-006-0252-3

Cite this article as:
Milch, C.E., Salem, D.N., Pauker, S.G. et al. J Gen Intern Med (2006) 21: 165. doi:10.1007/s11606-006-0252-3

Abstract

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 words

medical errorsadverse eventserror reporting systemselectronic reporting

Copyright information

© Society of General Internal Medicine 2006

Authors and Affiliations

  • Catherine E. Milch
    • 1
  • Deeb N. Salem
    • 2
  • Stephen G. Pauker
    • 3
  • Thomas G. Lundquist
    • 3
    • 4
    • 5
    • 6
  • Sanjaya Kumar
    • 7
  • Jack Chen
    • 7
  1. 1.Department of Medicine and the Institute for Clinical Research and Health Policy StudiesTufts-New England Medical CenterBostonUSA
  2. 2.Department of Medicine, Division of CardiologyTufts-New England Medical CenterBostonUSA
  3. 3.Department of Medicine, Division of Clinical Decision MakingTufts-New England Medical CenterBostonUSA
  4. 4.I-trax Health Management SolutionsPhiladelphiaUSA
  5. 5.Department of PediatricsNemours Children’s HospitalJacksonvilleUSA
  6. 6.Bryn Mawr HospitalBryn MawrUSA
  7. 7.Quantros Inc.MilpitasUSA