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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†∥

Journal of Patient Safety: March 2009 - Volume 5 - Issue 1 - p 9-15
doi: 10.1097/PTS.0b013e318198dc8d
Original Articles

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.

From the *Division of General Medicine and Primary Care, Brigham and Women's Hospital; †Harvard Medical School; ‡Harvard School of Public Health; §Patient Safety Group, Brigham and Women's Hospital, Boston; and ∥Office of Patient Safety and Clinical Affairs, Partners HealthCare, Needham, Massachusetts.

Correspondence: Osnat Levtzion-Korach, MD, MHA, Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston MA 02120 (e-mail:

Support for this research was provided by the Agency for Healthcare Research and Quality (Rockville, Maryland) and by rL Solutions (Toronto, Ontario, Canada). The data were collected independently, and the article was developed independently without input from the funding sources.

© 2009 Lippincott Williams & Wilkins, Inc.