title: Design and implementation of a near-miss reporting system at a large, academic pediatric anesthesia department.
abstract: BACKGROUND
  Current incident reporting systems encourage retrospective reporting of morbidity and mortality and have low participation rates. A near miss is an event that did not cause patient harm, but had the potential to. By tracking and analyzing near misses, systems improvements can be targeted appropriately, and future errors may be prevented.
  
  
  METHODS
  An electronic, web based, secure, anonymous reporting system for anesthesiologists was designed and instituted at The Children's Hospital, Denver. This portal was compared to an existing hospital incident reporting system.
  
  
  RESULTS
  A total of 150 incidents were reported in the first 3 months of operation, compared to four entered in the same time period 1 year ago.
  
  
  CONCLUSIONS
  An anesthesia-specific anonymous near-miss reporting system, which eases and facilitates data entry and can prospectively identify processes and practices that place patients at risk, was implemented at a large, academic, freestanding children's hospital. This resulted in a dramatic increase in reported events and provided data to target and drive quality and process improvement.
authors.affiliation: Department of Anesthesiology, The Children's Hospital and University of Colorado School of Medicine, Denver, CO, USA. guffey.patrick@tchden.org
authors.forename: Patrick
authors.initials: P
authors.lastname: Guffey
authors.forename: Judit
authors.initials: J
authors.lastname: Szolnoki
authors.forename: James
authors.initials: J
authors.lastname: Caldwell
authors.forename: David
authors.initials: D
authors.lastname: Polaner
mesh_terms: D000046:Academic Medical Centers; D000761:Anesthesia Department, Hospital / Q000458:organization & administration*; D002648:Child; D016494:Computer Security; D003625:Data Collection; D057286:Electronic Health Records; D017052:Hospital Mortality; D006801:Humans; D020407:Internet; D007591:Joint Commission on Accreditation of Healthcare Organizations; D019300:Medical Errors; D010372:Pediatrics; D012306:Risk; D012308:Risk Management / Q000458:organization & administration*; D014481:United States