Reporting and using near-miss events to improve patient safety in diverse primary care practices: A collaborative approach to learning from our mistakes

Steven Crane, Philip D. Sloane, Nancy Elder, Lauren Cohen, Natascha Laughtenschlaeger, Kathleen Walsh, Sheryl Zimmerman

Research output: Contribution to journalArticlepeer-review

21 Scopus citations

Abstract

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.

Original languageEnglish (US)
Pages (from-to)452-460
Number of pages9
JournalJournal of the American Board of Family Medicine
Volume28
Issue number4
DOIs
StatePublished - Jul 1 2015
Externally publishedYes

Keywords

  • Medical errors
  • Physician's practice patterns
  • Practice management
  • Quality of health care

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Family Practice

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