• Margaret L Plews-Ogan, Mohan M Nadkarni, Sue Forren, Darlene Leon, Donna White, Don Marineau, John B Schorling, and Joel M Schectman.
• University of Virginia Health Systems, Charlottesville, VA 22908, USA. mp5k@virginia.edu
• J Gen Intern Med. 2004 Jul 1; 19 (7): 719725719-25.

BackgroundVoluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis.ObjectivesTo determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting.DesignWe report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice.SettingInternal medicine practice site of a large teaching hospital with 25,000 visits per year.Measurements And Main ResultsThere were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period.ConclusionThis model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

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