Nonpunitive Method Improves Medical Error Reporting

Most common errors: misfiled or incorrectly entered patient info

MONDAY, Nov. 21 (HealthDay News) -- Medical error reporting in an academic pediatric ambulatory practice can be improved by a voluntary, nonpunitive, error-reporting system, according to a study published online Nov. 21 in Pediatrics.

Daniel R. Neuspiel, M.D., M.P.H., from the Levine Children's Hospital in Charlotte, N.C., and colleagues used a team-based approach to promote patient safety, and described errors following implementation of a nonpunitive error-reporting system. The multidisciplinary team detected and analyzed ambulatory medical errors in an academic general pediatric practice with approximately 26,000 annual visits, mainly serving a low-income, Medicaid-insured population. The team utilized systems analysis and rapid redesign to assess each error, and suggested changes to prevent harm to patients.

The investigators found that, compared with five reports in the year before the project, 216 medical errors were identified in 30 months. The majority of the reports originated from nurses, physicians, and midlevel providers. Misfiled or erroneously entered patient information was the most frequently reported error. Together with delayed or not performed laboratory tests, errors in medication prescriptions or dispensing, vaccine errors, patients not being given requested appointments or referrals, and delays in office care accounted for 76 percent of the reports. Many of the recommendations were implemented.

"A voluntary, nonpunitive, multidisciplinary team approach was effective in improving error reporting, analyzing reported errors, and implementing interventions with the aim of reducing patient harm in an outpatient pediatric practice," the authors write.

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