Capturing More Emergency Department Errors Via an Anonymous Web-based Reporting System

Khare, Rahul K.; Uren, Brad; Wears, Robert L.

doi:10.1097/00019514-200504000-00004

Cited by 9 publications

(7 citation statements)

References 5 publications

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“…Anonymous, Web-based reporting systems offer convenience and anonymity and are thought to improve error reporting. 17 Previously described error reduction techniques have included standardization of processes (adapting "critical pathways" and guidelines), formal teamwork training, 18 minimizing interruptions, 19 increasing attention to the highrisk elements of health care (such as patient care transitions), introducing redundancy and resilience into systems, 20 and implementation of appropriate information technology (such as prescription order entry systems).…”

Section: Discussionmentioning

confidence: 99%

Errors, near misses and adverse events in the emergency department: What can patients tell us?

Friedman

Provan

Moore

et al. 2008

CJEM

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Objective: We sought to determine whether patients or their families could identify adverse events in the emergency department (ED), to characterize patient reports of errors and to compare patient reports to events recorded by health care providers. Methods: This was a prospective cohort study in a quaternary care inner city teaching hospital with approximately 40 000 annual visits. ED patients were recruited for participation in a standardized interview within 24 hours of ED discharge and a follow-up interview 3-7 days after discharge. Responses regarding events were tabulated and compared with physician and nurse notations in the medical record and hospital event reporting system. Results: Of 292 eligible patients, 201 (69%) were interviewed within 24 hours of ED discharge, and 143 (71% of interviewees) underwent a follow-up interview 3-7 days after discharge. Interviewees did not differ from the base ED population in terms of age, sex or language. Analysis of patient interviews identified 10 adverse events (5% incident rate; 95% confidence interval [CI] 2.41%-8.96%), 8 near misses (4% incident rate; 95% CI 1.73%-7.69%) and no medical errors. Of the 10 adverse events, 6 (60%) were characterized as preventable (2 raters; κ = 0.78, standard error [SE] 0.20; 95% CI 0.39-1.00; p = 0.01). Adverse events were primarily related to delayed or inadequate analgesia. Only 4 out of 8 (50%) near misses were intercepted by hospital personnel. The secondary interview elicited 2 out of 10 adverse events and 3 out of 8 near misses that had not been identified in the primary interview. No designation (0 out of 10) of an adverse event was recorded in the ED medical record or in the confidential hospital event reporting system. Conclusion: ED patients can identify adverse events affecting their care. Moreover, many of these events are not recorded in the medical record. Engaging patients and their family members in identification of errors may enhance patient safety. RÉSUMÉObjectif : Nous avons cherché à déterminer si les patients ou leurs familles pouvaient détecter des événements indésirables à l'urgence, à caractériser les rapports d'erreurs des patients et à comparer les rapports des patients aux événements consignés par les fournisseurs de soins de santé. Méthodes : Nous avons réalisé une étude de cohorte prospective dans un hôpital universitaire de soins quaternaires du centre-ville qui compte environ 40 000 visites annuellement. Nous avons recruté des patients à l'urgence pour participer à une entrevue normalisée dans les 24 heures suivant ORIGINAL RESEARCH • RECHERCHE ORIGINALE EM ADVANCES

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Section: Discussionmentioning

confidence: 99%

Errors, near misses and adverse events in the emergency department: What can patients tell us?

Friedman

Provan

Moore

et al. 2008

CJEM

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“…Optimally, an anonymous web-based error reporting system should allow all staff to report errors without fear of consequence; nevertheless, this does not seem to be the case. Khare et al [9] found three factors preventing error reporting: fear, futility and hassle. It may be possible to create an environment in which error reporting is non-punitive, and the specter of litigation persists.…”

Section: Discussionmentioning

confidence: 99%

Error reporting in the emergency department: do we do what we say we do?

Jeanmonod

Katz²

2012

World Journal of Emergency Medicine

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“…Exactly how many is unknown. Some believe that reported errors represent only a fraction of those that actually occur (Khare, Uren, & Wears, 2005).…”

Section: Overview Of Errors In the Emergency Departmentmentioning

confidence: 99%

“…Khare et al (2005) classified the barriers to error reporting into three factors: the fear factor, the futility factor, and the hassle factor. A staff member may feel fearful that he or she will be identified as the person who reported the error.…”

Section: Recovering and Reporting Medical Errors 99mentioning

confidence: 99%

“…• skepticism of the benefits of reporting • fear of reprisals • lack of trust in the organization • difficulty in reporting the incident or lack of time • benefits of reporting are unclear • perceived risk of civil litigation Khare et al (2005) developed a Web-based incident reporting system for use by the ED staff or other departments that receive patients from the ED. The person reporting the incident is asked to categorize the error into one of eight themes: medication related, misdiagnosis, inappropriate disposition, procedural complication, delay in treatment, problem with equipment, problem with consultant, and other.…”

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confidence: 99%

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Recovering and Reporting Medical Errors in the Emergency Department

Gilboy¹,

Tanabe

2008

Advanced Emergency Nursing Journal

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The Research to Practice column attempts to serve 2 purposes: (1) fine-tune the research critique skills of advanced practice nurses and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research article is then reviewed and critiqued, and finally, the implications for translation into practice are discussed. In this column, the following article has been reviewed: Henneman, Blank, Gawlinski, and Henneman (2006). Qualitative methods were used to conduct 4 focus groups with emergency department nurses to understand how nurses recover medical errors. Key words: emergency department, medical error, nurses, qualitative research T HE Research to Practice column attempts to serve two purposes: (1) finetune the research critique skills of advanced practice nurses (APNs) and (2) suggest strategies to translate findings from a research study into bedside practice. For each column, a topic and a particular research study are selected. The stage is set by introducing the importance of the topic. The research article is then reviewed and critiqued, and finally, the implications for translation into practice are discussed.

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Capturing More Emergency Department Errors Via an Anonymous Web-based Reporting System

Abstract: A Web-based error reporting implemented in this manner may improve error reporting because of the convenience it offers and the option of anonymity. More reporting should create more opportunities for system improvement.

Cited by 9 publications

References 5 publications

Errors, near misses and adverse events in the emergency department: What can patients tell us?

Errors, near misses and adverse events in the emergency department: What can patients tell us?

Error reporting in the emergency department: do we do what we say we do?

Recovering and Reporting Medical Errors in the Emergency Department

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