To advance our collective knowledge about developing systems that prevent and buffer errors, we must gather information about the types and causes of injuries associated with them. Tools to collect and analyze confidential data on incidents and errors, and then provide actionable feedback, will foster learning and have a substantial impact on patient safety. A key issue has been that the tools to analyze and learn from the reported errors and adverse events are insufficient. To address this issue we will develop, implement and/or design the following: 1. A secure web-based portal for confidential reporting of errors and adverse events to a related but separate organization, which will increase the rate of reporting. 2. Stratifying reports to help local safety officers and hospital administrators identify and prioritize practical actions for prevention, which will increase the impact of reporting. 3. Developing tools to determine if the system impact of stratified feedback reports will be feasible and helpful in ongoing errors and adverse event feedback. 4. Stimulating reports will increase the rate of reporting and will provide data about errors and adverse event prevalence that may complement estimates from single reporters about the likelihood of recurrence. 5. An automated error/adverse event detection method using triggers from embedded data will detect errors/adverse events that are different from those that are spontaneously reported. 6. Our experience with improving reporting rates will be shared throughout the network of Premier 1500 hospitals.
| Kaushal, Rainu; Goldmann, Donald A; Keohane, Carol A et al. (2010) Medication errors in paediatric outpatients. Qual Saf Health Care 19:e30 |
| Lemer, Claire; Bates, David W; Yoon, Catherine et al. (2009) The role of advice in medication administration errors in the pediatric ambulatory setting. J Patient Saf 5:168-75 |
| Zandieh, Stephanie O; Goldmann, Donald A; Keohane, Carol A et al. (2008) Risk factors in preventable adverse drug events in pediatric outpatients. J Pediatr 152:225-31 |
