TY - JOUR
T1 - Reporting and using near-miss events to improve patient safety in diverse primary care practices
T2 - A collaborative approach to learning from our mistakes
AU - Crane, Steven
AU - Sloane, Philip D.
AU - Elder, Nancy
AU - Cohen, Lauren
AU - Laughtenschlaeger, Natascha
AU - Walsh, Kathleen
AU - Zimmerman, Sheryl
N1 - Publisher Copyright:
© 2015, American Board of Family Medicine. All rights reserved.
PY - 2015/7/1
Y1 - 2015/7/1
N2 - Purpose: 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.
AB - Purpose: 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.
KW - Medical errors
KW - Physician's practice patterns
KW - Practice management
KW - Quality of health care
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U2 - 10.3122/jabfm.2015.04.140050
DO - 10.3122/jabfm.2015.04.140050
M3 - Article
C2 - 26152435
AN - SCOPUS:84937153756
SN - 1557-2625
VL - 28
SP - 452
EP - 460
JO - Journal of the American Board of Family Medicine
JF - Journal of the American Board of Family Medicine
IS - 4
ER -