Journal of Patient Safety

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Journal of Patient Safety:
doi: 10.1097/PTS.0b013e318198dc8d
Original Articles

Evaluation of the Contributions of an Electronic Web-based Reporting System: Enabling Action

Levtzion-Korach, Osnat MD, MHA*†; Alcalai, Hanna BPT, MHA*; Orav, Endel John PhD*†‡; Graydon-Baker, Erin MS, RRT§; Keohane, Carol BSN, RN*; Bates, David W. MD, MSc*†‡; Frankel, Allan S. MD†∥

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Background: Incident reporting represents a key tool in safety improvement. Electronic voluntary reporting systems have been perceived as advantageous compared to paper approaches and are increasingly being implemented.

Objectives: To evaluate the rate, content, ease of use, reporters' profile, and the follow-up and actions resulting from reports submitted to a Web-based electronic reporting system.

Methods: Analysis of the submitted reports to a commercial Web-based reporting system at a tertiary care academic hospital for 31 months between May 2004 and November 2006.

Results: During the study period, 14,179 reports were submitted. The leading incident categories were labs (30%), followed by medication issues (17%), falls (11%), and blood bank (10%). Of the reported incidents, 24% were near misses, 61% were adverse events that caused no harm, 14% caused temporary harm, 0.4% caused permanent harm, and 0.1% caused death. Of the eligible staff, 29% submitted a report during the study period. Physicians submitted only 2.9% of the reports; most reports were submitted by nurses, pharmacists, and technicians. Physicians tended to report on more severe cases and focused on different topics than other professionals. Overall, 84% of the reports came from the inpatient setting. On average, it took 14 minutes to submit a report. In following up on reports, first manager review was completed within a median of 22 hours, and a mean of 4 people reviewed each report. A large array of actions followed the reports.

Conclusions: This application effectively captured incidents, actions, and follow-up. Ease of data manipulation facilitated descriptive statistical analysis, and the ability to use branching algorithms may have helped in decision making about actions and follow-up.

© 2009 Lippincott Williams & Wilkins, Inc.


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