JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.

Three main strategies should be pursued to improve patient safety. A safety management system involving error reporting, learning from errors, and the fair exchange of information should be established in hospitals and in doctors' outpatient practices. An error management system should be implemented in which critical incidents are identified, reported, and analyzed so that similar events can be prevented, and measures for the prevention of critical incidents and errors should also be implemented and evaluated. Finally, whenever preventable adverse events do occur, the persons involved should take action to prevent further harm to the patient and other involved individuals.

Background :Despite awareness that comparative analysis of patient safety data from several data sources would promote risk reduction, there has been little eff ort to establish an incident classifi cation system that is generally applicable to patient safety data in European primary care. Objective : To describe the development of a patient safety incident classifi cation system for primary care. Methods : A systematic review was followed by an expert group discussion and a modifi ed Delphi survey, to provide consensus statements. Results : We developed a classifi cation system providing a mechanism for classifying patient safety incidents across Europe, taking into account the varying organizational arrangements that exist for primary care. It takes into account organizational processes and outcomes related to patient safety incidents and can supplement existing classifi cation systems. Conclusion:Classifi cation systems are key tools in the analysis of patient safety incidents. A system that has relevance for primary care is now available.

ZusammenfassungIn Anlehnung an bestehende Systeme in Australien, der Schweiz und Großbritannien wurde im September 2004 erstmals ein freiwilliges Fehlerberichtssystem auch in Deutschland eingerichtet. Das System ist Internet-basiert, unbeschränkt zugänglich, vollständig anonym und unabhängig. In der ersten Ausbaustufe wird das Feedback über die wöchentliche und monatliche Veröffentlichung beispielhafter Fehlerberichte gegeben. Außerdem besteht die Möglichkeit der Online-Diskussion. Dieser Artikel diskutiert die für Erfolg und Wirkung von Berichtssystemen notwendigen Eigenschaften. -Nach vier Monaten im Routinebetrieb werden kontinuierlich Fehler (in begrenzter Anzahl) berichtet, und auf der Internetseite wird intensiv diskutiert. Für eine erste explorative Datenauswertung standen 85 Fehlerberichte zur Verfügung. Die Klassifikation nach der PCISME/LIN-NAEUS-Taxonomie zeigte, dass 66 % Prozessfehler und 33 % Kenntnis-oder Fertigkeitsfehler waren. Die Einteilung nach dem Schweregrad der Fehler zeigte, dass 34 % der Fehler vorü-bergehenden oder dauerhaften Schaden verursacht hatten. 55 % der Fehler beinhalteten Medikationsfehler, und bei 46 % der Fehler spielten Probleme bei der Kommunikation eine Rolle. -Verschiedene Argumentationen des Risikomanagements führen zu dem Schluss, dass freiwillige Fehlerberichtssysteme spezifische, begrenzte Funktionen haben, um Bedrohungen der Patientensicherheit zu identifizieren. Sie sind eine wichtige Datenquelle, besonders für Beinahefehler, die in der offiziellen Erfassung nicht erscheinen. Die Etablierung von Fehlerberichtssystemen AbstractConsidering examples in Australia, Switzerland, UK a voluntary error reporting system was established in Germany in September 2004. The system is web-based with unrestricted access, completely anonymous and independent. Feedback is provided (in the first development level) by displaying exemplary error reports every week and every month and facilities for online discussion. The article discusses basic requirements that lead to success and impact of report systems.After four months of operation there is a limited but continuous flow of error reports and an intense online discussion about the examples. For a preliminary explorative data analysis 85 error reports were available. Classification following the PCISME/LINNAEUS taxonomy showed that 66 % were process errors and 33 % were knowledge or skills errors; grading according to severity showed: 34 % of errors caused temporary or permanent harm. 55 % of the reports contained medication errors and in 46 % of the reports communication was a contributory factor. Different arguments in risk management lead to the conclusion that voluntary error reporting systems have a specific, non-exclusive function in identifying threats to patient safety and are an important source of data, particularly on near misses which will not appear in official registrations. To establish error reporting systems in ambulatory care is more difficult than in organized hospital settings, and it is especially important to prov...

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