RT Journal Article
SR Electronic
T1 Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes
JF The Journal of the American Board of Family
                Medicine
JO J Am Board Fam Med
FD American Board of Family Medicine
SP 452
OP 460
DO 10.3122/jabfm.2015.04.140050
VO 28
IS 4
A1 Steven Crane
A1 Philip D. Sloane
A1 Nancy Elder
A1 Lauren Cohen
A1 Natascha Laughtenschlaeger
A1 Kathleen Walsh
A1 Sheryl Zimmerman
YR 2015
UL http://www.jabfm.org/content/28/4/452.abstract
AB 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.