Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care

Pfoh, Elizabeth R. MPH, PhD*; Engineer, Lilly MD, DrPH, MHA*†; Singh, Hardeep MD, MPH‡§; Hall, Laura Lee PhD; Fried, Ethan D. MD, MS; Berger, Zackary MD, PhD*†**; Wu, Albert W. MD, MPH*†

doi: 10.1097/PTS.0000000000000317
Review Article: PDF Only

Objective Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents.

Methods This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development.

Results Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)–related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology.

Conclusions Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.

From the *Johns Hopkins School of Medicine; †Johns Hopkins School of Public Health, Baltimore, Maryland; ‡Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center; §Baylor College of Medicine, Houston, Texas; ∥American College of Physicians, Washington, District of Columbia; ¶Hofstra Northwell School of Medicine at Lenox Hill Hospital, New York, New York; and **Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland.

Correspondence: Elizabeth R. Pfoh, MPH, PhD, 2024 E. Monument St, Suite 2-516 F, Baltimore, MD (e-mail:

The authors disclose no conflict of interest.

Definitions of types of patient safety events: incidents—patient safety events that reached the patient, whether there was harm; near misses or close calls—patient safety events that did not reach the patient; and unsafe conditions—circumstances that increase the probability of a patient safety event.

Funding: This work was supported by a grant from The Doctors Company Foundation to the American College of Physicians. Dr Singh is supported by the Veteran Administration Health Services Research and Development Service (CRE 12–033; Presidential Early Career Award for Scientists and Engineers USA 14–274), the Veteran Administration National Center for Patient Safety, the Agency for Health Care Research and Quality (R01HS022087) and in part by the Houston Veteran Administration HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413). Dr Pfoh is supported by a training grant from the Health Resources and Services Administration (T32HP10025B0).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved