Accession Number:

ADA433908

Title:

The Impact of a Patient Safety Program on Medical Error Reporting

Descriptive Note:

Corporate Author:

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY ROCKVILLE MD

Personal Author(s):

Report Date:

2005-05-01

Pagination or Media Count:

11.0

Abstract:

Background In response to the occurrence of a sentinel event a medical error with serious consequences Eglin U.S. Air Force USAF Regional Hospital developed and implemented a patient safety program called Medical Team Management MTM that was modeled on the aviation industrys Crew Resource Management program and focused on communication, teamwork, and reporting. Objective To determine the impact of a patient safety program on patterns of medical error reporting. Methods This study was a retrospective review of 1,102 incident reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001. Collected data from the comparison periods 1998 and 2001 was statistically analyzed using the chi-square test. Results The number of reports submitted increased significantly from 200 for 4,671 hospital admissions in 1998 to 276 for 4,003 admissions in 2001 chi-squared 28.38, P 0.0001. Evaluation of incident severity showed 172 86 percent near misses no impact on patient in 1998 and 251 91 percent in 2001. In 1998 there were 28 14 percent adverse events patient minimally effected and 25 9 percent in 2001 chi-squared 3.302, P 0.069. Analysis by rank of person filing the report revealed 39 reports submitted by junior nurses and 11 submitted by junior enlisted personnel in 1998, while in 2001 those numbers increased to 75 and 24 reports, respectively chi-squared 6.554, P 0.161. Conclusion This study indicates that, since the implementation of MTM, there has been a statistically significant increase in the number of reports filed at Eglin USAF Regional Hospital. Similarly, the severity of incidents shows an overall decline approaching statistical significance. Although there was an increase in reporting from junior team members, this was not statistically significant. These findings suggest that there have been changes in the patterns of error reporting since the implementation of MTM.

Subject Categories:

  • Medicine and Medical Research
  • Statistics and Probability
  • Human Factors Engineering and Man Machine Systems

Distribution Statement:

APPROVED FOR PUBLIC RELEASE