PMID- 11903759
OWN - NLM
STAT- MEDLINE
DCOM- 20020418
LR  - 20181113
IS  - 0884-8734 (Print)
IS  - 1525-1497 (Electronic)
IS  - 0884-8734 (Linking)
VI  - 16
IP  - 12
DP  - 2001 Dec
TI  - A physician-based voluntary reporting system for adverse events and medical 
      errors.
PG  - 809-14
AB  - OBJECTIVE: To create a voluntary reporting method for identifying adverse events 
      (AEs) and potential adverse events (PAEs) among medical inpatients. DESIGN: 
      Medical house officers asked their peers about obstacles to care, injuries or 
      extended hospitalizations, and problems with medications that affected their 
      patients. Two independent reviewers coded event narratives for adverse outcomes, 
      responsible parties, preventability, and process problems. We corroborated house 
      officers' reports with hospital incident reports and conducted a retrospective 
      chart review. SETTING: The cardiac step-down, oncology, and medical intensive 
      care units of an urban teaching hospital. INTERVENTION: Structured confidential 
      interviews by postgraduate year-2 and -3 medical residents of interns during work 
      rounds. MEASUREMENTS AND MAIN RESULTS: Respondents reported 88 events over 3 
      months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 
      patients (4.9% of admissions). Delayed diagnoses and treatments figured 
      prominently among PAEs (54%). Clinicians were responsible for the greatest number 
      of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), 
      and pharmacy (3%). Respondents identified a variety of problematic processes of 
      care, including problems with diagnosis (16%), therapy (26%), and failure to 
      provide clinical and support services (29%). We corroborated 84% of reported 
      events in the medical record. Participants found voluntary peer reporting of 
      medical errors unobtrusive and agreed that it could be implemented on a regular 
      basis. CONCLUSIONS: A physician-based voluntary reporting system for medical 
      errors is feasible and acceptable to front-line clinicians.
FAU - Weingart, S N
AU  - Weingart SN
AD  - Division of General Medicine and Primary Care, Beth Israel Deaconess Medical 
      Center, and Harvard Medical School, Boston, MA 02215, USA. 
      sweingar@caregroup.harvard.edu
FAU - Callanan, L D
AU  - Callanan LD
FAU - Ship, A N
AU  - Ship AN
FAU - Aronson, M D
AU  - Aronson MD
LA  - eng
PT  - Journal Article
PL  - United States
TA  - J Gen Intern Med
JT  - Journal of general internal medicine
JID - 8605834
SB  - IM
MH  - *Adverse Drug Reaction Reporting Systems
MH  - Feasibility Studies
MH  - Hospitals, Teaching
MH  - Humans
MH  - Medical Errors/*classification
MH  - *Physician's Role
MH  - Retrospective Studies
PMC - PMC1495298
EDAT- 2002/03/21 10:00
MHDA- 2002/04/19 10:01
PMCR- 2002/12/01
CRDT- 2002/03/21 10:00
PHST- 2002/03/21 10:00 [pubmed]
PHST- 2002/04/19 10:01 [medline]
PHST- 2002/03/21 10:00 [entrez]
PHST- 2002/12/01 00:00 [pmc-release]
AID - 10231 [pii]
AID - 10.1111/j.1525-1497.2001.10231.x [doi]
PST - ppublish
SO  - J Gen Intern Med. 2001 Dec;16(12):809-14. doi: 10.1111/j.1525-1497.2001.10231.x.