title: Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes.
abstract: OBJECTIVE
  Near-miss events represent an opportunity to identify and correct errors that jeopardize patient safety. This study was undertaken to assess the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them.
  
  
  METHODS
  We implemented a web-based, anonymous near-miss reporting system into 7 diverse practices, collecting and categorizing all reports. At the end of the study period, we interviewed practice leaders to determine how the near-miss reports were used for quality improvement (QI) in each practice.
  
  
  RESULTS
  All 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 QI projects based on the reports. The most frequent events reported were breakdowns in office processes (47.3%); of these, filing errors were most common, with 38% of these errors judged by external coders to be high risk for an adverse event. Electronic medical records were the primary or secondary cause of the error in 7.8% and 14.4% of reported cases, respectively. The pattern of near-miss events across these diverse practices was similar.
  
  
  CONCLUSIONS
  Anonymous near-miss reporting can be successfully implemented in primary care practices. Near-miss events occur frequently in office practice, primarily involve administrative and communication problems, and can pose a serious threat to patient safety; they can, however, be used by practice leaders to implement QI changes.
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE). steven.crane@msj.org.
authors.forename: Steven
authors.initials: S
authors.lastname: Crane
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Philip D
authors.initials: PD
authors.lastname: Sloane
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Nancy
authors.initials: N
authors.lastname: Elder
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Lauren
authors.initials: L
authors.lastname: Cohen
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Natascha
authors.initials: N
authors.lastname: Laughtenschlaeger
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Kathleen
authors.initials: K
authors.lastname: Walsh
authors.affiliation: From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina-Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
authors.forename: Sheryl
authors.initials: S
authors.lastname: Zimmerman
mesh_terms: D003299:Cooperative Behavior; D057286:Electronic Health Records; D005240:Feasibility Studies; D006801:Humans; D020407:Internet; D007858:Learning; D000067491:Near Miss, Healthcare / Q000706:statistics & numerical data*; D009657:North Carolina; D061214:Patient Safety / Q000592:standards* / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration* / Q000706:statistics & numerical data; D012308:Risk Management / Q000379:methods*
keywords: Medical Errors; Physician's Practice Patterns; Practice Management; Quality of Health Care