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The Psychiatry Morbidity and Mortality Incident Reporting Tool Increases Psychiatrist Participation in Reporting Adverse Events

Kroll, David S., MD*†; Shellman, Andrea D., MHSA; Gitlin, David F., MD*†

doi: 10.1097/PTS.0000000000000505
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Objectives Although the reporting of adverse events (AEs) is widely thought to be a key first step to improving patient safety in hospital systems, underreporting remains a common problem, particularly among physicians. We aimed to increase the number of safety reports filed by psychiatrists in our hospital system.

Methods We piloted an online survey for psychiatry-specific AE reporting, the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMIRT) for a 1-year period. An e-mail prompt containing a link to the survey was sent on a weekly basis to all psychiatry department clinical staff. The primary outcome was the total number of events reported by psychiatrists through PMIRT; secondary outcomes were the total number of AEs and the number of serious harm events filed by psychiatrists in our hospital's formal event reporting system before and after implementation of the new protocol.

Results Psychiatrists filed 65 reports in PMIRT during the study period. The average number of AEs reported by psychiatrists in the hospital's formal event reporting system significantly increased after the intervention (P = 0.0251), and the average number of serious harm events reported by psychiatrists increased nonsignificantly (P = 0.1394).

Conclusions The combination of an increase in awareness of event reporting with a psychiatry-specific AE reporting tool resulted in a significant improvement in the number of reports by psychiatrists.

From the *Department of Psychiatry, Brigham and Women's Hospital;

Harvard Medical School; and

Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts.

Correspondence: David S. Kroll, MD, Department of Psychiatry, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (e-mail: dskroll@bwh.harvard.edu).

D.S.K. has received research funding and an honorarium from Avasure, LLC. The other authors disclose no conflict of interest.

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