A physician-based voluntary reporting system for adverse events and medical errors.
OBJECTIVE
To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients.


METHODS
Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review.


METHODS
The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital.


METHODS
Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds.


RESULTS
Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis.


CONCLUSIONS
A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians.
Weingart
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Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA 02215, USA. sweingar@caregroup.harvard.edu
Callanan
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Ship
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Aronson
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MD
D016907:Adverse Drug Reaction Reporting Systems; D005240:Feasibility Studies; D006784:Hospitals, Teaching; D006801:Humans; D019300:Medical Errors / Q000145:classification*; D010819:Physician's Role; D012189:Retrospective Studies