Evaluation of an anonymous system to report medical errors in pediatric inpatients

J Hosp Med. 2007 Jul;2(4):226-33. doi: 10.1002/jhm.208.

Abstract

Objective: To compare reports of medical errors in hospitalized children submitted using an electronic, anonymous reporting system with those submitted via traditional incident reports.

Study design: During the 3-month study period in 2003, reports of medical errors from 2 units at a large children's hospital were made using an electronic, anonymous system. Three reviewers independently evaluated each report and determined whether the events described constituted a medical error. An identical procedure was used to categorize medical error data collected via incident reports from the 2 study units from 1999 to 2002.

Results: A total of 146 reports were made using the anonymous system, 131 of which documented medical errors. The rate of reporting medical errors with the anonymous system was 2.41/100 patient-days. The rate of reporting medical errors via incident reports in 1999-2002 was 2.40/100 patient-days. However, 33.8% of all incident reports dealt with mislabeled laboratory specimens; after excluding these reports, the rate of medical errors documented via incident reports was 1.56/100 patient-days. The rate of reporting was significantly higher with the anonymous system (rate ratio 1.54, 95% confidence interval 1.26, 1.90). With the anonymous system, 25.2% of reported medical errors were near-misses compared with 12.6% of the errors reported with the incident report system (P = .001).

Conclusions: Implementation of the anonymous reporting system with training was associated with a statistically significant increase in the rate of reported medical errors. The reporting of near-miss events was significantly increased, suggesting this may be a useful format for gathering data on this type of medical error.

Publication types

  • Evaluation Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Documentation / standards
  • Hospitals, Pediatric / standards*
  • Humans
  • Inpatients*
  • Medical Errors / classification
  • Medical Errors / prevention & control
  • Medical Errors / statistics & numerical data*
  • Medication Systems, Hospital / standards
  • Risk Management / methods*
  • Total Quality Management / methods
  • Washington