Re-engineering the medication error-reporting process: removing the blame and improving the system. Going paperless with custom-built Web-based patient occurrence reporting. Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.
A hospital's change from a traditional, multitiered incident-reporting system for medication errors to a standardized, nonpunitive medication-use variance process is described. After weaknesses were identified in the hospital's system for reporting and evaluating medication errors, a multidisciplinary task force was formed to redesign the hospital's medication error-reporting system. Its guiding principles were as follows: anonymity and freedom from punitive action are essential for increasing the number of reports, rating medication errors facilitates identification of areas for system improvement, potential errors provide valuable insight into the system's vulnerabilities, and timely review of reports enables rapid systematic correction. To support the intended nonpunitive culture, the term medication-use variance was used in lieu of medication error for any unplanned event that deviates from the intended course of prescribing, dispensing, administering, or monitoring medications. A one-page medication-use variance report was developed that prompted the reporter for key data elements, including root causes, patient outcomes, and possible ways to prevent similar incidents. The most difficult decision for the task force was deciding whether the process should be anonymous. After getting the support of the medical-legal counsel and the quality improvement department for an anonymous reporting process, the task force agreed to test it in the department of pharmacy and in three patient units in September 1998. A paper-driven reporting process was selected initially because an electronic system would not be truly anonymous. The number of reports from these units increased compared with historical trends, and for the first time potential errors were reported. The report form was easy to use and improved the interpretation of reports. Despite these positive results, task force members remained divided on the issue of anonymity but ultimately embraced the nonpunitive culture. In the first six months following hospitalwide implementation, the number of events captured increased more than fivefold; it continues to increase. The resulting database serves as a trigger for quality improvement efforts and a measure of their effectiveness. The redesign of the medication error-reporting process served as the impetus for a change in the organizational culture surrounding medication errors. Baylor University Medical Center (Dallas) converted patient occurrence reporting from a paper form to a custom-built Web-based system that used the medical center's intranet. DEVELOPING THE WEB-BASED SYSTEM: Non-medication patient occurrences were documented manually on paper forms known as incident reports, and medication variances were entered electronically. The medical center had used the same paper form for many years, without any interim updates or revisions. With a delay of more than a week in receiving forms, the process was not efficient or timely. In addition, paper forms were sometimes illegible or incomplete.
                The project team, representing the Center for Quality and Care Coordination and information services, decided that the best approach would be a phased implementation based on development of system functionality and a facility's readiness for conversion. Reporting was to be conducted in terms of 10 standardized patient occurrence reporting categories.
                Comparison of quarterly data pre- and post-Web forms showed an 83.5% increase in number of submissions and a 79.5% reduction in event-to-submission time. Web forms also eliminated paper form limitations of legibility, completeness, and security.
                It is still an individual responsibility to report and then transform collected data into usable information, which will drive process improvement. Technology can make an important contribution to these efforts, but the culture of the organization must have a complete program strategy. The focus must shift to reporting as a cornerstone to quality and safety and away from traditional notions of error and blame. To design a Web-based system to track adverse and near-miss events, to establish an automated method to identify patterns of events, and to assess the adverse event reporting behavior of physicians.
                A Web-based system was designed to collect physician-reported adverse events including weekly Morbidity and Mortality (M&M) entries and anonymous adverse/near-miss events. An automated system was set up to help identify event patterns. Adverse event frequency was compared with hospital databases to assess reporting completeness.
                A metropolitan tertiary care center.
                Identification of adverse event patterns and completeness of reporting.
                From September 2005 to August 2007, 15,524 surgical patients were reported including 957 (6.2%) adverse events and 34 (0.2%) anonymous reports. The automated pattern recognition system helped identify 4 event patterns from M&M reports and 3 patterns from anonymous/near-miss reporting. After multidisciplinary meetings and expert reviews, the patterns were addressed with educational initiatives, correction of systems issues, and/or intensive quality monitoring. Only 25% of complications and 42% of inpatient deaths were reported. A total of 75.2% of adverse events resulting in permanent disability or death were attributed to the nature of the disease. Interventions to improve reporting were largely unsuccessful.
                We have developed a user-friendly Web-based system to track complications and identify patterns of adverse events. Underreporting of adverse events and attributing the complication to the nature of the disease represent a problem in reporting culture among surgeons at our institution. Similar systems should be used by surgery departments, particularly those affiliated with teaching hospitals, to identify quality improvement opportunities.