Improving reporting of outpatient pediatric medical errors

Abstract

Objective: Limited information exists about medical errors in ambulatory pediatrics and on effective strategies for improving their reporting. We aimed to implement nonpunitive error reporting, describe errors, and use a team-based approach to promote patient safety in an academic pediatric practice.

Patients and methods: The setting was an academic general pediatric practice in Charlotte, North Carolina, that has ∼26 000 annual visits and primarily serves a diverse, low-income, Medicaid-insured population. We assembled a multidisciplinary patient safety team to detect and analyze ambulatory medical errors by using a reporter-anonymous nonpunitive process. The team used systems analysis and rapid redesign to evaluate each error report and recommend changes to prevent patient harm.

Results: In 30 months, 216 medical errors were reported, compared with 5 reports in the year before the project. Most reports originated from nurses, physicians, and midlevel providers. The most frequently reported errors were misfiled or erroneously entered patient information (n = 68), laboratory tests delayed or not performed (n = 27), errors in medication prescriptions or dispensing (n = 24), vaccine errors (n = 21), patient not given requested appointment or referral (n = 16), and delay in office care (n = 15), which together comprised 76% of the reports. Many recommended changes were implemented.

Conclusions: A voluntary, nonpunitive, multidisciplinary team approach was effective in improving error reporting, analyzing reported errors, and implementing interventions with the aim of reducing patient harm in an outpatient pediatric practice.