Voluntary Anonymous Reporting of Medical Errors for Neonatal Intensive Care

• Gautham Suresh

  University of Vermont College of Medicine, Burlington, Vermont

• Jeffrey D. Horbar

  University of Vermont College of Medicine, Burlington, Vermont

• Paul Plsek

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• James Gray

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• William H. Edwards

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• Patricia H. Shiono

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• Robert Ursprung

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• Julianne Nickerson

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

• Jerold F. Lucey

  University of Vermont College of Medicine, Burlington, Vermont

• Donald Goldmann

  Center for Patient Safety in Neonatal Intensive Care, University of Vermont, Burlington, Vermont

抄録

Objectives. Medical errors cause significant morbidity and mortality in hospitalized patients. Specialty-based, voluntary reporting of medical errors by health care providers is an important strategy that may enhance patient safety. We developed a voluntary, anonymous, Internet-based reporting system for medical errors in neonatal intensive care, evaluated its feasibility, and identified errors that affect high-risk neonates and their families. Methods. Health professionals (n = 739) from 54 hospitals in the Vermont Oxford Network received access to a secure Internet site for anonymous reporting of errors, near-miss errors, and adverse events. Reports used free-text entry in phase 1 (17 months) and a structured form in phase 2 (10 months). The number and types of reported events and factors that contributed to the events were measured. Results. Of 1230 reports—522 in phase 1 (17 months) and 708 in phase 2 (10 months)—the most frequent event categories were wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products; 47%); error in administration or method of using a treatment (14%); patient misidentification (11%); other system failure (9%); error or delay in diagnosis (7%); and error in the performance of an operation, procedure, or test (4%). The most frequent contributory factors were failure to follow policy or protocol (47%), inattention (27%), communications problem (22%), error in charting or documentation (13%), distraction (12%), inexperience (10%), labeling error (10%), and poor teamwork (9%). In 24 reports, family members assisted in discovery, contributed to the cause, or themselves were victims of the error. Serious patient harm was reported in 2% and minor harm in 25% of phase 2 events. Conclusions. Specialty-based, voluntary, anonymous Internet reporting by health care professionals identified a broad range of medical errors in neonatal intensive care and promoted multidisciplinary collaborative learning. Similar specialty-based systems have the potential to enhance patient safety in a variety of clinical settings.

収録刊行物

• Pediatrics

  Pediatrics 113 (6), 1609-1618, 2004-06-01

  American Academy of Pediatrics (AAP)

キーワード

• Pediatrics, Perinatology and Child Health

詳細情報

• CRID: 1364233271282787456
• NII論文ID: 30012915823
• DOI: 10.1542/peds.113.6.1609
• ISSN: 10984275
• ISSN: 00314005
• Web Site: https://publications.aap.org/pediatrics/article-pdf/113/6/1609/1004169/zpe00604001609.pdf
• データソース種別:
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  • CiNii Articles