Database Design to Ensure Anonymous Study of Medical Errors: A Report from the ASIPS collaborative

Pace, Wilson D.; Staton, Elizabeth W.; Higgins, Gregory S.; Main, Deborah S.; West, D. R. F.; Harris, Daniel M.

doi:10.1197/jamia.m1339

Cited by 25 publications

(25 citation statements)

References 8 publications

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“…15 It is modeled on the Federal Aviation Administration (FAA) Aviation Safety Reporting System, which is widely recognized as a major success. 12,16,17 Similar to the FAA reporting system, the ASIPS research team represents an outside third party: the project is not directly attached to any institutional quality improvement group, nor does any team member supervise those making reports.…”

Section: The Patient Safety Reporting Systemmentioning

confidence: 99%

“…In all cases, contact information was automatically expunged from the database within 10 days of submission. 15 Practices (not individual reporters) were paid $50 for each completed confi dential follow-up interview to offset the cost of time taken for the interview. Reporting forms and interviewers did not In your opinion, was (were) the patient(s) harmed as a result of this event?…”

Section: Reporting Eventsmentioning

confidence: 99%

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Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative

Fernald

Pace²,

Harris³

et al. 2004

The Annals of Family Medicine

131

116

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BACKGROUNDWe examined reports to a primary care, ambulatory, patient safety reporting system to describe types of errors reported and differences between anonymous and confi dential reports.METHODS Applied Strategies for Improving Patient Safety (ASIPS) is a demonstration project designed to collect and analyze medical error reports from clinicians and staff in 2 practice-based research networks: the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). A major component of ASIPS is a voluntary patient safety reporting system that accepts reports of errors anonymously or confi dentially. Reports are coded using a multiaxial taxonomy.RESULTS Two years into this project, 33 practices with a total of 475 clinicians and staff have participated in ASIPS. Participants submitted 708 reports during this time (66% using the confi dential reporting form). We successfully followed up on 84% of the confi dential reports of interest within the allotted 10-day time frame. We ended up with 608 relevant, codable reports. Communication problems (70.8%), diagnostic tests (47%), medication problems (35.4%), and both diagnostic tests and medications (13.6%) were the most frequently reported errors. Confi dential reports were signifi cantly more likely than anonymous reports to contain codable data.CONCLUSION A safe and secure reporting system that relies on voluntary reporting from clinicians and staff can be successfully implemented in primary care settings. Information from confi dential reports appears to be superior to that from anonymous reports and may be more useful in understanding errors and designing interventions to improve patient safety.

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Section: The Patient Safety Reporting Systemmentioning

confidence: 99%

Section: Reporting Eventsmentioning

confidence: 99%

Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative

Fernald

Pace²,

Harris³

et al. 2004

The Annals of Family Medicine

131

116

View full text Add to dashboard Cite

show abstract

“…10 -14 Anonymous reporting systems may increase the number of error reports and reduce concerns about punitive actions but might reduce the detail of the events. 15,16 There is value in including all office staff in a reporting system, but this strategy may require frequent reminders to keep reporting volumes from dwindling. 17 While errors occur frequently in primary care, few seem to result in significant harm to patients, consistent with the "near-miss" nature of many of these errors.…”

mentioning

confidence: 99%

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Crane

Sloane

Elder

et al. 2015

The Journal of the American Board of Family Medicine

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Purpose: Near-miss events represent an opportunity to identify and correct errors that jeopardize patient safety. This study was undertaken to assess the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them.Methods: We implemented a web-based, anonymous near-miss reporting system into 7 diverse practices, collecting and categorizing all reports. At the end of the study period, we interviewed practice leaders to determine how the near-miss reports were used for quality improvement (QI) in each practice.Results: All 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 QI projects based on the reports. The most frequent events reported were breakdowns in office processes (47.3%); of these, filing errors were most common, with 38% of these errors judged by external coders to be high risk for an adverse event. Electronic medical records were the primary or secondary cause of the error in 7.8% and 14.4% of reported cases, respectively. The pattern of near-miss events across these diverse practices was similar.Conclusions: Anonymous near-miss reporting can be successfully implemented in primary care practices. Near-miss events occur frequently in office practice, primarily involve administrative and communication problems, and can pose a serious threat to patient safety; they can, however, be used by practice leaders to implement QI changes. (J Am Board Fam Med 2015;28:452-460.)

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“…Preliminary attempts focused on broad categories of errors such as "gaps in knowledge," "administrative failure," "treatment delivery lapse," and "miscommunication." 7,8 Applied Strategies for Improving Patient Safety (ASIPS) 9 used a detailed, multi-axial taxonomy containing 10 axes within 4 domains 10 to code safety events. The overall ASIPS project developed and implemented an ambulatory primary care error reporting system, received and analyzed error reports, and implemented interventions to improve patient safety.…”

mentioning

confidence: 99%

Harm Resulting from Inappropriate Telephone Triage in Primary Care

Hildebrandt¹,

Westfall²,

Fernald³

et al. 2006

The Journal of the American Board of Family Medicine

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Purpose: Our objective was to assess and categorize harm occurring to patients who called their physicians' office after-hours but did not have their call forwarded to the physician because they stated that their call was not an emergency.Methods: We collected data on 4949 calls handled by our answering service for 1 year in a family medicine residency office in Denver, CO. Of the 2835 after-hours clinical calls, we reviewed all 288 clinical calls that were not forwarded to the "on-call" physician. Complete data on 119 clinical calls included reason for call, frequency of next day appointments, Emergency Department visits, hospital admissions and outcomes. Outcomes were reviewed and coded for harm to the patient by experienced medical errors coders.Results: When patient calls were not forwarded, 51% had an appointment, 4% an Emergency Department visit, and 2% were admitted to the hospital within 2 weeks. Analysis revealed that 3% suffered harm, and 26% experienced discomfort due to the delay. Although 66% required no intervention, 1% required emergency transport and 4% a medication change. Conclusions: Harm may occur when patients' calls are not forwarded to the on-call physician. Although the level of harm is generally temporary and minimal, the potential exists for serious harm to occur. Physicians need to re-evaluate the way they handle after-hours calls. (J Am Board Fam Med 2006; 19:437-42.)Over the past 10 years, the majority of studies of patient safety have focused on the hospital setting. A great deal of time, money, and energy has been spent identifying types of errors and system problems.1-3 The frequency of errors has varied from 6% to 18% with only a small portion of those errors resulting in permanent harm or death to the patients treated. 4 Naturally, serious harm has garnered the most attention. 5 Recently, attention has been focused on the ambulatory care settings, where errors may be even more frequent. For example, in the ambulatory care setting, adverse drug events may occur at a rate that is 4 times higher than that found in the hospital setting.

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Database Design to Ensure Anonymous Study of Medical Errors: A Report from the ASIPS collaborative

Cited by 25 publications

References 8 publications

Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative

Event Reporting to a Primary Care Patient Safety Reporting System: A Report From the ASIPS Collaborative

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Harm Resulting from Inappropriate Telephone Triage in Primary Care

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