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How a system for reporting medical errors can and cannot improve patient safety
Journal article   Open access   Peer reviewed

How a system for reporting medical errors can and cannot improve patient safety

John R Clarke
The American surgeon, v 72(11), pp 1088-1091
Nov 2006
PMID: 17120952
url
https://doi.org/10.1177/000313480607201118View
Published, Version of Record (VoR)Maybe Open Access (Publisher Bronze) Open

Abstract

Guidelines as Topic Humans Management Information Systems - standards Mandatory Reporting Medical Errors - statistics & numerical data United States
The Institute of Medicine has recommended systems for reporting medical errors. This article discusses the necessary components of patient safety databases, steps for implementing patient safety reporting systems, what systems can do, what they cannot do, and motivations for physician participation. An ideal system captures adverse events, when care harms patients, and near misses, when errors occur without any harm. Near misses signal system weaknesses and, because harm did not occur, may provide insight into solutions. With an integrated system, medical errors can be linked to patient and team characteristics. Confidentiality and ease of use are important incentives in reporting. Confidentiality is preferred to anonymity to allow follow-up. Analysis and feedback are critical. Reporting systems need to be linked to organizational leaders who can act on the conclusions of reports. The use of statistics is limited by the absence of reliable numerators and denominators. Solutions should focus on changing the cultural environment. Patient safety reporting systems can help bring to light, monitor, and correct systems of care that produces medical errors. They are useful components of the patient safety and quality improvement initiatives of healthcare systems and they warrant involvement by physicians.

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Web of Science research areas
Surgery
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