When health care practitioners are allowed to report medical errors anonymously in a non-punitive environment designed to improve patient safety, many more errors will be reported, according to a recent study published in Pediatrics.
Daniel R. Neuspiel, MD, MPH, and colleagues at Levine Children’s Hospital in Charlotte, N.C., implemented non-punitive error reporting and created a team-based approach to patient safety in an academic pediatric practice. The practice handles about 26,000 annual visits per year and serves a diverse, low-income population.
By putting together a multidisciplinary patient safety team to detect and analyze medical errors, the researchers hoped to improve error reporting and use the information to recommend changes to prevent further errors from occurring. The patient safety team used systems analysis and rapid redesign to evaluate every error report and suggest changes.
In the 30 months of the program, 216 medical errors were reported. In the year before the program, only five errors were reported. According to the authors, most of the error reports came from nurses, physicians, and midlevel providers. The most frequently reported errors were misfiled or erroneously entered patient information, delayed or neglected laboratory tests, prescription or dispensing errors, vaccine errors, patients not given requested appointments or referrals, and delays in office care.
These errors accounted for 76% of the reports. The patient safety team met monthly to discuss solutions to the root causes of the errors. The authors reported that numerous recommended changes were implemented, and that asking health care practitioners to voluntarily report errors with no fear of punishment was effective in improving error reporting and implementing solutions to the errors themselves.