title: A Novel Patient Safety Event Reporting Tool in Otolaryngology.
abstract: Objective To report the results of a preliminary analysis of a quality improvement initiative aimed to identify potential latent systems defects. Methods A pilot study of an anonymous, voluntary, event reporting system made available to all members of the American Academy of Otolaryngology-Head and Neck Surgery was performed. The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was used to classify error types. Descriptive statistics were used to summarize submissions to the database. Results In the 53 cases reported to the database over 22 months, the majority involved errors that had resulted in harm (n = 34, 64%), followed by errors that occurred and did not result in harm (n = 7, 13%). Errors occurred predominantly in the hospital (n = 23, 44%) and operating room (n = 19, 35%). Most entries were classified as either technical (n = 21, 39%) or related to postoperative care (n = 15, 30%). Discussion This preliminary descriptive analysis of a novel otolaryngology patient safety event reporting tool shows that this platform brings unique value to the identification of errors and adverse events in our specialty. Most reported events were classified as errors resulting in harm. The most common type of reported event was a technical error, most often resulting in a nerve injury. Implications for Practice This reporting tool will likely allow for identification and prioritization of improvement opportunities. This example may serve as a guide for other societies to create similar platforms as we strive for a standardized process for event reporting.
authors.affiliation: 1 Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.
authors.forename: Peter M
authors.initials: PM
authors.lastname: Vila
authors.affiliation: 2 Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York, USA.
authors.forename: Sean
authors.initials: S
authors.lastname: Lewis
authors.affiliation: 3 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.
authors.forename: Gene
authors.initials: G
authors.lastname: Cunningham
authors.affiliation: 3 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, Virginia, USA.
authors.forename: Jean
authors.initials: J
authors.lastname: Brereton
authors.affiliation: 4 Division of Pediatric Otolaryngology, Children's National Health System, George Washington University, Washington, DC, USA.
authors.forename: Alexandra G
authors.initials: AG
authors.lastname: Espinel
authors.affiliation: 5 Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Roberson
authors.affiliation: 4 Division of Pediatric Otolaryngology, Children's National Health System, George Washington University, Washington, DC, USA.
authors.forename: Rahul K
authors.initials: RK
authors.lastname: Shah
mesh_terms: D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data*; D010036:Otolaryngology; D061214:Patient Safety; D010865:Pilot Projects; D058996:Quality Improvement
keywords: PS/QI; incident reporting; voluntary patient safety event reporting