Many more medical errors are reported when the process is anonymous and the health-care environment is nonpunitive, study results published in Pediatrics indicate.
Daniel R. Neuspiel, MD, MPH, of Levine Children’s Hospital in Charlotte, North Carolina, and colleagues implemented an anonymous error reporting system at the practice, based on a team approach to patient safety. They hoped the program would improve error reporting and that the information they gathered would help guide efforts to prevent further errors from occurring.
In the 30 months after program implementation, 216 medical errors were reported vs. just five in the year prior to program implementation, with most of the error reports coming from nurses, physicians and midlevel providers, the researchers found.
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The most frequently reported errors, accounting for 76% of reports, were as follows:
- Misfiled or erroneously entered patient information
- Delayed or neglected laboratory tests
- Prescription or dispensing errors
- Vaccine errors
- Patients not given requested appointments or referrals
- Delays in office care
As part of the program, the patient safety team also met monthly to discuss potential solutions to the root causes of the errors and implemented numerous recommended changes during the study period.
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, the researchers concluded.
Neuspeil DR et al. Pediatrics. 2011; doi: 10.1542/peds.2011-0477.
