Physician reporting of clinically significant events through a computerized patient sign-out system

J Patient Saf. 2011 Sep;7(3):155-61. doi: 10.1097/PTS.0b013e31822d7a66.


Objectives: : Although electronic reporting systems for near-misses and adverse events have been implemented nationwide, physician participation in such systems has typically been very limited. Previous efforts to improve such rates have met with some success but may be costly and time-consuming. To improve events reporting rates at our academic medical center, we incorporated a physician reporting module into the computer software that house officers already use for their daily sign-out routine.

Methods: : During the period between January 1 and June 30, 2009, house staff were asked to report a set of 13 predefined "clinically significant events" such as cardiopulmonary arrests and unexpected transfers to the intensive care unit. Entries were maintained in an administrative data collection module and were reviewed daily by the residency program director and chief residents.

Results: : House staff reported approximately 12 incidents per month. A survey of the intern class (the heaviest users of system) showed that the principal barriers to physician reporting at our facility were related to ease of use, time pressure, and fear of disciplinary actions. Information gleaned from the reports has been useful in modifying a number of patient care processes on the medicine service.

Conclusions: : Our experience suggests that if a training program makes it easy for the house officer to report events during routine work duties, by integrating the reporting system into the tools of daily patient care, physicians will become willing participants in the process. A handheld version of such a reporting system holds promise for even greater physician participation in the future.

MeSH terms

  • Disclosure*
  • Fear
  • Humans
  • Internship and Residency*
  • Medical Staff, Hospital / psychology*
  • Patient Safety
  • Risk Management*
  • Time Factors