title: Detection of medical errors in kidney transplantation: a pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system.
abstract: BACKGROUND
  Rates of medical errors and adverse events remain high for patients who undergo kidney transplantation; they are particularly vulnerable because of the complexity of their disease and the kidney transplantation procedure. Although institutional incident-reporting systems are used in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems.
  
  
  METHODS
  Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011, and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported.
  
  
  RESULTS
  A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared with incident reports, more attending physicians completed the debriefings (32.0 vs 3.5%).
  
  
  CONCLUSIONS
  The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL. Electronic address: lisa.mcelroy@northwestern.edu.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: McElroy
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Amna
authors.initials: A
authors.lastname: Daud
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Brittany
authors.initials: B
authors.lastname: Lapin
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Olivia
authors.initials: O
authors.lastname: Ross
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Donna M
authors.initials: DM
authors.lastname: Woods
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Anton I
authors.initials: AI
authors.lastname: Skaro
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Jane L
authors.initials: JL
authors.lastname: Holl
authors.affiliation: Center for Healthcare Studies, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, IL.
authors.forename: Daniela P
authors.initials: DP
authors.lastname: Ladner
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D020407:Internet; D016030:Kidney Transplantation; D008297:Male; D019300:Medical Errors; D008875:Middle Aged; D061214:Patient Safety; D010865:Pilot Projects; D012308:Risk Management / Q000458:organization & administration*