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Service Delivery Innovation Profile

Voluntary, Anonymous, Non-Punitive System Leads to a Significant Increase in Reporting of Errors in Ambulatory Pediatric Practice


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Snapshot

Summary

A hospital’s ambulatory pediatrics department developed a voluntary, anonymous, and nonpunitive medical error reporting system that includes a quick response team to review reports and enact interventions to prevent recurrences. The program significantly increased the reporting of medical errors and near-misses, leading to the implementation of numerous changes designed to improve safety.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation data on the number of formal incident reports, along with post-implementation tracking of interventions implemented as a result of the reports.
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Developing Organizations

Beth Israel Medical Center, Department of Pediatrics
New York, NYend do

Use By Other Organizations

A similar voluntary, anonymous, and nonpunitive error reporting program was implemented by the Department of Internal Medicine at the University of Virginia Health Systems, yielding similar increases in error reporting (from 5 to 100 after 1 year).

In addition, a similar program was implemented successfully at Myers Park Pediatrics, an academic general pediatrics practice in Charlotte, North Carolina that is part of Levine Children’s Hospital of Carolinas Medical Center.5 In 30 months, 216 medical errors were reported, compared to 5 reports in the year pre-implementation; error reports led to many recommended safety-related process changes.

Date First Implemented

2006

Problem Addressed

More people die from medical errors than from motor vehicle accidents, breast cancer, or acquired immunodeficiency syndrome each year. Many medical error or incident reporting systems are punitive and focus on holding individual providers accountable.1 Rarely do reporting systems seek information about systemic flaws, minor medical errors, or “near-misses” that could lead to improved patient safety.
  • A common, preventable problem: Two large studies found that medical mistakes occurred in 2.9 and 3.7 percent of hospitalizations, respectively. In both studies, more than half of the adverse events could have been prevented.1 For adults, the reported incidence of errors in treatment with medications ranges from 1 to 30 percent of all hospital admissions, with errors occurring in roughly 5 percent of all written orders. In pediatrics, the comparable figure can be as high as 15 percent, with errors reported to occur in as many as 1 in 6.4 orders.2
  • Inadequacy of mandatory reporting systems: Despite increased attention to patient safety and the study of medical error prevention, physicians and other providers may be reluctant to report errors except those with the most obvious and serious consequences because of uncertainty about how to make the report, concern about the time and effort required, lack of involvement in development of the reporting system,3 and the legal implications and lawsuits that may ensue (because many mandatory reporting systems focus on blaming individuals for errors). Although mandatory reporting systems give providers and hospitals the ability to address some issues that threaten patient safety (primarily those related to individual failings), the reported serious incidents represent only the "tip of the iceberg" and do not capture less serious incidents or the many systemic problems that can lead to serious errors.1
  • Underuse of voluntary reporting systems: In contrast to mandatory systems, voluntary reporting systems can focus on near-misses or errors that result in minimal patient harm that often signal the existence of systemic or department weaknesses in health care delivery. Voluntary reports are usually submitted in confidence, with no penalties or fines issued. However, few health care organizations have voluntary error reporting systems in place, particularly in the outpatient setting. Studies suggest that medication errors alone may occur in 15 to 22 percent of outpatient encounters, yet most remain unreported.4
  • Similar problems at Beth Israel: Beth Israel’s pediatrics ambulatory department lacked a culture of error reporting and analysis. In 2005, there were 36,000 patient visits to the outpatient pediatric department, yet only five medical error reports were filed.

What They Did

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Description of the Innovative Activity

To encourage staff to report more medical errors and near-misses, Beth Israel's pediatric ambulatory department created a simple, anonymous medical error report form, and provided dropoff boxes that anyone can use to submit a report. A pediatric safety champion team committee, with representatives from all practice staff disciplines, reviews each report, identifies the root cause(s) of the error or near-miss, develops interventions to address the cause(s), and produces a monthly report on the errors and their solutions. Key elements of the program are described in further detail below:

  • Report forms to elicit key facts: The report asks for the following: patient name, date, description of the error (such as paper filed in wrong chart or miswritten vaccine order), how long it took to recognize the error after it occurred, how the error was discovered, who discovered the error (name or job title), age of patient, and whether the error resulted in injury or harm to the patient. The report also asks the submitter to speculate on what could have been done to prevent the error.
  • Discrete, easy report submission: The error report form and receptacles for them are located throughout the pediatrics department to enable easy and discreet report submission. During the launch of the new reporting initiative, employees were reminded about the new process and safety team members wore pins promoting patient safety and the reporting system. Pediatric safety champion team members submit reports themselves and encourage others to do so when they witness any errors or near-misses. Any error that involves patient injury and/or otherwise meets the criteria for mandatory event reporting at the hospital is also reported to appropriate hospital officials.
  • Monthly review of reports: Using a one-page review form, the team reviews each error or near-miss to identify the problems and associated root causes. The team categorizes each report as relating to administrative, laboratory or other testing, on- or offsite medication or treatment, or communication. The team also brainstorms and recommends potential interventions to address the root cause(s), with resulting recommendations being categorized as to whether they affect education, systems, or equipment, and whether they are an easy fix that can be done immediately, a more complex issue that needs further work, or an issue that requires collaboration with other departments. Examples of the output from the review and intervention process include the following:
    • Avoiding communication errors: One report revealed that a child with varicella (chicken pox), which is highly contagious, had been seated in the waiting room for 30 minutes, exposing children and adults to the infection. The committee created a strategy to alert reception staff to children with fever and rash so they can be isolated, including posting a sign on the front door asking parents or caregivers to tell the receptionist if their child has a fever and rash.
    • Avoiding falls: Patients, caregivers, and staff often tripped on scales located in examination rooms; the committee had the scales relocated to another part of the room.
    • Correcting filing errors: Missing or misfiled laboratory reports and medical records were found in patient charts. The patient safety committee met with medical record supervisors and found out who had performed the filing (which could be determined by the patient account number included on the error-report form). The supervisors then met with these staff members to find out how the errors happened and correct them.
    • Faster pickup for laboratory specimens: Laboratory specimens were occasionally not getting picked up by couriers in a timely manner (the laboratory is located within the hospital). Committee members met with laboratory management to revise the courier system.
    • Avoiding medication errors: There were several reports of wrong vaccines being administered to children. The committee’s response was to decrease interactions with the nurses as they prepare the vaccines, thus reducing distractions and the chance of error. The new policy requires nurses to go into the preparation room and keep the door closed to deter other staff from interrupting them. In another example, error reports pointed to problems interpreting physicians’ handwriting in prescription orders. The department worked with physicians to achieve more consistent naming conventions for medications, including spelling out brand names (instead of using initials).
  • Ongoing monitoring and monthly reports: The committee regularly monitors progress on the interventions and reports on findings related to both reports and solutions in the department's monthly newsletter. This publicity encourages staff to continue reporting errors and near-misses.

Context of the Innovation

Phillips Ambulatory Care Center, one of four Beth Israel Medical Center sites in New York City, houses all of the teaching hospital's adult and pediatric outpatient services and offers primary and specialty care services. Beth Israel's ambulatory pediatric department had a culture that did not embrace the reporting of errors, with only five reports being submitted in 2005. To address this problem, department leaders looked to error-reporting models from other industries, most notably NASA’s Aviation Safety Reporting System, which uses voluntary, confidential reporting of minor problems that affect or could affect aircraft safety to identify and address these issues before they result in more serious disasters. Beth Israel modified NASA's approach to create its own voluntary, nonpunitive reporting system combined with team review and response to the problems identified.

Did It Work?

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Results

This program significantly increased the number of reports and near-misses, leading to the implementation of numerous patient safety improvements in this academic pediatric ambulatory practice.
  • Increase in reports of errors and near-misses: In 2006, 80 errors and near-misses were reported, a 15-fold increase over the five reports in the previous year. Everyone embraced the program, with reports originating from physicians (45 percent), nurses (41 percent), other staff (9 percent), and even parents/patients (5 percent). Roughly one-third of reports were classified as involving office administration (34 percent), while just under one-fourth involved medications and other treatment (24 percent). The remainder involved laboratory and diagnostic testing (19 percent) or communications (18 percent). The 80 reports during 2006 represented only 0.2 percent of patient encounters, however, suggesting that errors and near-misses were still being under-reported. By 2008, the program experienced an additional 10 percent increase in reports. The distribution of error types remained very similar to those in 2006, with office and administrative errors being the most common type, followed by errors related to medications, communication, and laboratory and diagnostic tests. The number of reports continued to increase steadily since 2007. In 2009, the number of reports increased 36 percent; however, the practice experienced a 12 percent increase in patient visits. Despite the continued increase in reports, there have been no errors that resulted in patient harm. The vast majority of errors were identified before actually reaching the patient. This in part is believed to be the result of a greater awareness by all staff.
  • Many patient safety improvements initiated: By the spring of 2008, 65 percent of reports had resulted in completed interventions and improvements, and additional changes were in development. Given the incompleteness of error reporting, it is difficult to quantitatively assess the clinical impact of these changes. However, the reports have brought to light many systemic issues and have created the impetus for changes that should have a broad impact on the practice and its patients. Examples of these changes include the following:
    • Installation of a half door on the vaccine preparation office to reduce interruptions and the risk of entry by small children
    • Modifications to progress notes to enhance the clarity of vaccine orders
    • Modifications to the culture log to make it easier to note when patients have been placed on treatment while awaiting results of cultures, thus assuring that the family will be advised to stop treatment if the culture result is negative
    • Provision of additional education to providers regarding clarity of medication orders
    • Movement of the medication list onto the problem list page to assure greater compliance with updates to both
    • System established to retrieve vaccine history from the immunization registry before visits by new patients to reduce the risk of vaccine errors when patients do not have their previous records available for the visit
    • Modifications suggested to the lab request sheets to enhance clarity of lab orders
    • Ongoing individual education has been provided as errors have been noted

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation data on the number of formal incident reports, along with post-implementation tracking of interventions implemented as a result of the reports.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Creation of a pediatric safety champion team: The team included representatives from across the practice, including registered nurses, licensed practical nurses, front desk and administrative staff, physicians, the nurse manager, and department leaders. The team was charged with encouraging reporting and developing practical solutions to the problems identified.
  • Developing the form: The pediatric safety champion team designed the error report form, including the type of events that should be reported. The report was structured to encourage the reporting of "any event in a patient’s medical care that did not go as intended and either harmed or could have harmed the patient.”

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as existing staff participate as part of their regular duties. The department head serves as a champion for the program, while representatives from various disciplines serve as part of the pediatric safety champion team.
  • Costs: Program costs are minimal, consisting primarily of expenses associated with implementing the recommended improvements.
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Funding Sources

Beth Israel Medical Center, Department of Pediatrics
The initiative was funded internally as a part of the department’s ongoing quality improvement efforts. end fs

Adoption Considerations

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Getting Started with This Innovation

  • Appoint safety champion team from all disciplines: An atmosphere of inclusion is critical to encouraging as many reports as possible. Include representatives from all practice staff disciplines, such as the medical director, a physician, nurse manager, office manager, registered nurse, licensed practical nurse, nursing care technicians, and patient service representative (registration and receptionist staff member).
  • Develop a user-friendly reporting form: Design and test the form, making modifications based on feedback from early users.
  • Use the team to promote reporting: Team members, who must be personally committed to improving patient safety, should educate coworkers about the project and encourage the initial reporting of errors.

Sustaining This Innovation

  • Maintain awareness of the system: To avoid a decline in reporting as providers get busy and initial enthusiasm over the program wanes, have team members periodically remind their peers to report errors and model desired behavior by reporting errors themselves.
  • Keep the focus on improvement through monthly reports: Continually publicizing improvements that result from error reports underscores the importance and effectiveness of the voluntary system.
  • Consider adding a patient or parent to team: Once the system is up and running, the addition of a patient or parent can provide a unique and valuable perspective to the team.

Use By Other Organizations

A similar voluntary, anonymous, and nonpunitive error reporting program was implemented by the Department of Internal Medicine at the University of Virginia Health Systems, yielding similar increases in error reporting (from 5 to 100 after 1 year).

In addition, a similar program was implemented successfully at Myers Park Pediatrics, an academic general pediatrics practice in Charlotte, North Carolina that is part of Levine Children’s Hospital of Carolinas Medical Center.5 In 30 months, 216 medical errors were reported, compared to 5 reports in the year pre-implementation; error reports led to many recommended safety-related process changes.

Additional Considerations

  • Because patient safety is a high priority at Beth Israel, the ambulatory pediatric department did not require any formal approval from hospital management before starting the voluntary reporting program.

More Information

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Contact the Innovator

Margo A. Guzman, RNC, MSN
Nurse Manager for Beth Israel Pediatric Associates
Phillips Ambulatory Care Center - Beth Israel Medical Center
10 Union Square East Suite 2 H and J
New York, NY 10003
(212) 844-8303
E-mail: mguzman@chpnet.org

Innovator Disclosures

Ms. Guzman has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Neuspiel DR, Stubbs EH, Liggin L. Improving reporting of outpatient pediatric medical errors. Pediatrics. 1 Dec 2011;128(6):e1608-e1613.

Plews-Ogan ML, Nadkarni M, Forren S, et al. Patient safety in the ambulatory setting. J Gen Intern Med. 2004;19(7):719-25. [PubMed]

Neuspiel D, Guzman M, Harewood C. Improving error reporting in ambulatory pediatrics with team approach. AHRQ Advances in Patient Safety: New Directions and Alternative Approaches. 2008. Available at: http://www.ahrq.gov/advancesvol1-Neuspiel.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).

Footnotes

1 Kohn L, Corrigan J, Donaldson M, editors. To Err Is Human: Building a Safer Health System. Report of the Institute of Medicine. Committee on Quality of Health Care in America. Washington, DC: Institute of Medicine; 2001. Available at: http://books.nap.edu/openbook.php?record_id=9728&page=1.
2 Committee on Drugs and Committee on Hospital Care. Policy statement: Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children. Prevention of Medication Errors in the Pediatric Inpatient Setting. Elk Grove Village, IL: American Academy of Pediatrics, 2003. Available at: http://www.illinoisaap.org/wp-content/uploads/06-Family-Centered-Care-Policy-Statement.pdf
3 Schechtman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43. [PubMed]
4 Neuspiel D, Guzman M, Harewood C. Improving error reporting in ambulatory pediatrics with team approach. AHRQ Advances in Patient Safety: New Directions and Alternative Approaches. 2008. Available at: http://www.ahrq.gov/advancesvol1-Neuspiel.pdf.
5 Neuspiel DR, Stubbs EH, Liggin L. Improving reporting of outpatient pediatric medical errors. Pediatrics. 1 Dec 2011;128(6):e1608-e1613.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 13, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.