miércoles, 25 de enero de 2017

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

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



 2015 Jul-Aug;28(4):452-60. doi: 10.3122/jabfm.2015.04.140050.

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

Abstract

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.

KEYWORDS:

Medical Errors; Physician's Practice Patterns; Practice Management; Quality of Health Care

PMID:
 
26152435
 
DOI:
 
10.3122/jabfm.2015.04.140050

[PubMed - indexed for MEDLINE] 
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