Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals.
OBJECTIVE
To describe the rate and types of events reported in acute care hospitals using an electronic error reporting system (e-ERS).


METHODS
Descriptive study of reported events using the same e-ERS between January 1, 2001 and September 30, 2003.


METHODS
Twenty-six acute care nonfederal hospitals throughout the U.S. that voluntarily implemented a web-based e-ERS for at least 3 months.


METHODS
Hospital employees and staff.


METHODS
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.
Milch
Catherine E
CE
Department of Medicine and the Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, MA 02111, USA.
Salem
Deeb N
DN
Pauker
Stephen G
SG
Lundquist
Thomas G
TG
Kumar
Sanjaya
S
Chen
Jack
J
D016907:Adverse Drug Reaction Reporting Systems; D006801:Humans; D020407:Internet; D019300:Medical Errors; D009726:Nurses / Q000706:statistics & numerical data; D010820:Physicians / Q000706:statistics & numerical data; D012308:Risk Management; D017751:Safety Management / Q000379:methods*; D035141:Voluntary Programs