National Study Evaluates Electronic Reporting of Medical Errors and Adverse Events

BOSTON -- Results from a multi-year survey of reports from hospitals using electronic adverse event and error reporting systems indicate that an estimated 34,000 patients a year could be seriously or permanently injured, or die, during hospitalization due to medical errors and adverse events.

The findings, based on an extensive study designed and managed by Tufts- New England Medical Center in Boston, come from analyses of 2.5 million patient days at 26 acute care hospitals across the U.S. The research also found:

* Among the errors that reached patients, the majority (67 percent) caused no harm, while the remaining third caused injury (32 percent temporary harm, less than 1 percent permanent or life threatening harm, and less than 0.5 percent contributing to patient death).

* Although computer reporting stations were easily accessible to all hospital employees, doctors entered fewer than two percent of all reported incidents, whereas registered nurses provided nearly half of all medical error reports.

* A total of 92,547 medical error and adverse events were reported. Although more than half of these involved patients, more than one-quarter were due to institutional safety issues or "near-misses" that did not affect patients.

The full study, funded in part by grants from the Ruth Kirschstein Individual National Research Service Award and the Agency for Health Research and Quality, was posted online today by the Journal of General Internal Medicine at http://www.blackwellpublishing.com. It will appear in the February 2006 print edition.

According to Tufts-New England Medical Center's Physician-in-Chief Deeb Salem, MD, this is the first time any extensive research had been conducted on electronic error reporting systems in the United States. "The study provides conclusive evidence that voluntary, online electronic reporting systems are playing an increasingly vital role in the nation's hospitals," said Salem, who is also the senior author of the study.

"An electronic system for reporting adverse events and medical errors may allow for easier identification and analysis of clinical practices that lead to adverse events and errors," said study lead author and Tufts-NEMC physician Catherine E. Milch, MD.  "Direct observation and chart review, two other commonly used methods, are time and labor intensive and impractical for rapid analysis. The next step is to determine if electronic reporting will decrease the incidence of severe injury and death to patients."

The researchers also emphasized that computer-based systems allow hospitals to collect four times more data than conventional methods; "near misses" are routinely recorded; and all data is peer-review protected on secure internal computer networks.

"Electronic error reporting systems will allow clinicians to gather real-life data, both now and as safer systems are implemented.  Such data are central to causing and sustaining change," said Stephen Pauker, MD, Tufts-NEMC's associate physician-in-chief and study co-author. "Gathering accurate data about medical errors is a necessary step toward making medical care safer."

  The study evaluated all reported events from 26 acute care non-profit, non-federal hospitals that had voluntarily implemented a system for at least three months (median range of usage was 21 months). Hospitals ranged in size from 120 to 582 beds. Twenty-four were adult or adult/pediatric care; two were exclusively pediatric; nine were academic medical centers; 11 were in urban, 13 in suburban, and two in rural settings.

The reporting system consisted of a secure, Web-based portal available on all hospital PCs. Any employee could submit a report after a secure login. The reporting process took an average of 10 minutes to complete. Collected data was only accessible to pre-specified hospital personnel, mostly chief medical officers and quality improvement executives.

Of the total 92,457 reports, 34 percent were non-medication related clinical events, 33 percent were medication related events, 13 percent were falls, 13 percent were administrative and six percent "other."  Of all error incidents, registered nurses reported 47 percent; pharmacists and pharmacy technicians 16 percent; lab technicians 10 percent; unit clerks/secretarial staff 10 percent; LPNs and nursing assistants three percent; and physicians 1.4 percent. Other reports came from medical assistants, security personnel, social workers, and risk case managers.

Source: Tufts-New England Medical Center