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

To the Editor: Near-miss reporting systems are a valuable tool for identifying errors that could cause patient harm.¹ Crane et al² demonstrated the feasibility of implementing these systems in diverse ambulatory care settings. However, the large financial incentives of both implementation and continued reporting of events limits the interpretation of this study. Large monthly monetary rewards for a set quantity of reports are likely to cloud the intention of near-miss reporting: to reduce errors that could cause patient harm.

There is certainly a monetary cost to the orientation and training required to implement a near-miss reporting system, yet the amount allotted in this study seems to far exceed typical costs. Even more concerning is the $1500 monthly incentive for reporting near-miss events and identifying an event to track. These monthly payments are a major potential bias regarding the quality and office buy-in of near-miss reporting. The authors defend these bonuses by stating that reporting continued after the payouts ceased, and that, based on group interviews, there were no concerns of staff feeling pressured to report. However, group interviews are not adequate to assess this issue because staff may not feel comfortable reporting these concerns without the opportunity to provide anonymous individual feedback. Even if there was no pressure to report, the inherent bias of these monetary incentives still stands. A simple way to eliminate this bias is to not include monetary incentives at all. Multiple studies demonstrate that near-miss reporting systems without a monetary incentive can be successful.^3⇓–5 These studies all note an increase in the reporting of near-miss events after implementation, similar to the findings in the study by Crane et al.² Our office uses a paper-based near-miss reporting system with office recognition of those members who consistently report. Each month our physicians and staff share the “good catches” with each other to reinforce good reporting practices. There are no monetary rewards, yet the quantity and quality of reporting has remained steady since implementation over 2 years ago.

A monetary incentive may assist in the implementation of near-miss reporting systems, but it may jeopardize the quality of reporting. For a practice to conduct quality near-miss reporting, the primary incentive for reporting should be to improve patient care. Large monetary incentives may shift this goal to reaching a monthly quantity of reporting events, and the quality or relevance of these reports could suffer. The model presented in this article may be useful for implementing a near-miss reporting system in settings that are not otherwise inclined to do so, but incentives should be cost-neutral at most. If possible, an ideal near-miss reporting system would be strictly voluntary, without monetary incentives, to avoid a major source of bias and keep the focus on improving patient care.