OBJECTIVE: Limited information exists about medical errors in ambulatory pediatrics and on effective strategies for improving their reporting. We aimed to implement nonpunitive error reporting, describe errors, and use a team-based approach to promote patient safety in an academic pediatric practice.
PATIENTS AND METHODS: The setting was an academic general pediatric practice in Charlotte, North Carolina, that has ∼26 000 annual visits and primarily serves a diverse, low-income, Medicaid-insured population. We assembled a multidisciplinary patient safety team to detect and analyze ambulatory medical errors by using a reporter-anonymous nonpunitive process. The team used systems analysis and rapid redesign to evaluate each error report and recommend changes to prevent patient harm.
RESULTS: In 30 months, 216 medical errors were reported, compared with 5 reports in the year before the project. Most reports originated from nurses, physicians, and midlevel providers. The most frequently reported errors were misfiled or erroneously entered patient information (n = 68), laboratory tests delayed or not performed (n = 27), errors in medication prescriptions or dispensing (n = 24), vaccine errors (n = 21), patient not given requested appointment or referral (n = 16), and delay in office care (n = 15), which together comprised 76% of the reports. Many recommended changes were implemented.
CONCLUSIONS: A voluntary, nonpunitive, multidisciplinary team approach was effective in improving error reporting, analyzing reported errors, and implementing interventions with the aim of reducing patient harm in an outpatient pediatric practice.
Knowledge is limited on medical errors and effective strategies for reducing patient harm in pediatric outpatient care. The Institute of Medicine has described the impact of medical errors on patients in the United States.1,–,3 To better understand and reduce these errors, more complete reporting is needed, yet traditional reporting systems are not very sensitive, are perceived by staff as punitive, and often exclude front-line staff from reporting and addressing medical errors.4,5 The Institute of Medicine has recommended blame-free reporting systems that encompass both adverse events and near-misses.
Seeking and identifying system flaws enable the development of strategies to prevent harm to patients. An understanding of system-based improvements in response to medical errors is also an important competency requirement for educating health professionals.6 Voluntary, team-based, nonpunitive error reporting has been effective in detecting and addressing errors in several clinical settings.4,7,–,10
The objectives of this project were to improve reporting of medical errors in a pediatric outpatient setting by using a nonpunitive reporting system and to test team-based system analysis, rapid redesign, and monitoring of change recommendations made in response to error reports. A secondary objective was to identify and describe the types of medical errors that occur in the pediatric outpatient setting.
PATIENTS AND METHODS
The setting of this project was Myers Park Pediatrics, the main general pediatric ambulatory teaching site for Levine Children's Hospital of Carolinas Medical Center in Charlotte, North Carolina. During the period of this project, the practice included continuity clinics for 33 pediatric residents, an acute care clinic staffed by pediatric and family medicine residents, midlevel providers and attending pediatricians, and a faculty practice staffed by attending pediatricians and midlevel providers. The practice is also a major clinical teaching site for students from the University of North Carolina School of Medicine and several nursing programs. During the project period, there were ∼26 000 patient visits per year. Medicaid was the primary payer for 90% of the patients, and others were covered by NC Health Choice (North Carolina's Children's Health Insurance Program) or private insurance or were uninsured. The ethnic identification of patients was 60% Hispanic, 30% black, and 10% white or other.
This quality improvement project was primarily observational: to detect and analyze ambulatory medical errors reported by using a nonpunitive process. Secondarily, an interventional component that used team-based systems analysis and rapid redesign to improve patient safety by reducing recurrence of specific errors was included.
In May 2008, a multidisciplinary “pediatric safety champion team” (heretofore referred to as “the team”) was assembled, following a similar model implemented in 2 other academic primary care practices: 1 adult practice4 and 1 pediatric practice.10 The team included members from all staff categories, including a front-end registrar, nurses, resident physician, midlevel provider, medical director, pediatric faculty, nurse manager, front-end manager, and practice manager. A voluntary, anonymous, nonpunitive reporting system commenced in June 2008. Before study initiation, all practice staff were educated and encouraged to report both adverse events and near-misses in the care of patients in the practice. The team was trained in system-based root-cause analysis using actual error scenarios from a similar project in another pediatric outpatient practice.10
An error was defined as “any event in a patient's medical care that did not go as intended and either harmed or could have harmed the patient.”4 Error reports were completed on standard forms and deposited in collection bins located in several areas of the practice. Reports were anonymous to reporter and included an event description, patient identification, job classification of the reporter, and suggestions for preventing similar events. During this project, the practice was transitioning from paper to an electronic medical record. Information on race or ethnicity of the affected patients was not reported.
The team met monthly to review error reports and conduct system-based root-cause analysis on novel reports. When needed, the team obtained further information from medical records. No patient contact was made by the team, which decided by consensus on recommended interventions to address the root causes of reported errors by using rapid-redesign methodology.11 Rapid redesign is a focused, facilitated method of process improvement that brings together improvement-team members to generate new processes or products over a short time period. At subsequent meetings, progress on implementation of changes was tracked. Monthly summaries of reported errors and recommended interventions were distributed to practice staff and discussed at monthly staff meetings. The frequency of error reports per month was compared with the number of patient visits per month by using a p chart, which is a type of statistical control chart to study how a process changes over time.12
This project was reviewed by the institutional review board of Carolinas Medical Center and determined to be exempt from review as a quality improvement project. Error reports were completed without identification of reporters, and members of the team understood the need for confidentiality with respect to affected patients. Errors that met criteria for hospital incident reporting were reported by using a separate established hospital system independent of the team's deliberation process.
During the first 30 months of the project, 216 medical errors were reported. In the 12-month period before initiation of the project, only 5 errors were reported through a traditional incident-reporting system, all related to medication or vaccine-administration errors.
An average of 7.2 errors per month (range: 1–18) were reported. Fig 1 shows a p chart12 with monthly error reports per visit volume, which ranged from 0.4 to 9.3 reports per 1000 visits. Only 2 months had a report rate above the upper control limits. In both of these high-rate months, there were 18 error reports received. In 1 of these months, November 2008, 7 children were affected by receiving a wrong vaccine. In the second high-rate month, July 2010, there was no perceived pattern of error type. The lower control limits were 0 for all months. There was no seasonal variation in error reporting or in errors per visit volume.
Table 1 lists the origin of error reports. Although 77% of errors were reported by nurses, physicians, and midlevel providers, other reports came from a variety of sources. Of the physician reports, some were identified as coming from pediatric residents, but others were not specifically known to originate from residents or faculty.
The most numerous specific errors are listed in Table 2. The most frequently reported errors were misfiled or erroneously entered patient information (n = 68), laboratory tests delayed or not performed (n = 27), errors in medication prescriptions or dispensing (n = 24), vaccine-related errors (n = 21), patient not given requested appointment or referral (n = 16), and delay in office care (n = 15). Together, these 6 error types comprised 76% of the reports. No errors resulted in significant harm to patients.
To date, 161 error reports (75%) have culminated in completed system changes, 40 errors (19%) involved nonsystem causes, and interventions for 15 errors (7%) are pending or had incomplete information to make a recommendation. Examples of completed interventions that addressed specific root causes are listed in Table 3. Some of these interventions have required collaborations with other departments, and many events were determined to have multiple root causes.
Voluntary, nonpunitive error reporting with team-based systems analysis and rapid redesign effectively increased error reporting in this academic pediatric ambulatory practice compared with a traditional hospital incident-reporting system. Many interventions have been implemented to reduce specific errors that have potential to cause patient harm.
The large increase in error reporting might have resulted from multiple factors, including staff education, efforts to overcome a traditional blaming culture, involvement of representatives from all staff categories in a safety team that encouraged and reviewed reports, and response of the practice staff to feedback on reported events and interventions. Endorsement of the project by practice leadership and participation of managers on the safety team helped to engage staff support and facilitated the implementation of recommended interventions. Ongoing education of clinicians, learners, and support staff was necessary for promoting the reporting of errors.
Results of this study provide further information on the diversity of causes of outpatient pediatric medical errors. Although most pediatric care in the United States is provided in an office setting, knowledge on the epidemiology of errors in this venue is limited.13 In 1 study, among new prescriptions for 22 common medications in outpatient pediatric clinics, 15% were issued with potential dosing errors.14 Medication samples are often dispensed with inadequate documentation.15 The Learning From Errors in Ambulatory Pediatrics study reported 147 medical errors from 14 practices.16 The largest number of them was related to medical treatment (37%), along with other mishaps in patient identification (22%), preventive care (15%), diagnostic testing (13%), patient communication (8%), and other causes. Among medical treatment errors, 85% were medication errors. Of these errors, 55% were related to ordering, 30% to failure to order, 11% to administration, and 2% to transcribing, and 2% were dispensing errors.
In a study at 6 Boston, Massachusetts, area pediatric practices over 2 months, 57 preventable adverse drug events occurred in the care of 1788 patients (a 3% rate).17 Although none of these events was deemed to be life-threatening, 8 (14%) were serious. Parenteral drug administration was associated with 40 (70%) of these events. Improved communication between providers and parents and between pharmacists and parents was the preventive strategy with the most potential. Children with multiple prescriptions were at higher risk of preventable adverse drug events.18 In the same Boston cohort, there were potentially harmful medication errors identified in 26% of the patient encounters.19
Our project was partially modeled on 2 outpatient efforts. An academic internal medicine site in Charlottesville, Virginia, achieved a 20-fold increase in reported ambulatory medical errors after implementation of a voluntary reporting process linked with systems analysis and redesign. As in our study, most of their reports were of errors that did not cause patient harm rather than adverse events.4 In an academic pediatric outpatient practice in New York City, New York, investigators established a multidisciplinary, voluntary, anonymous, nonpunitive reporting system paired with team-based system analysis and change implementation. In the first year, 80 errors were reported, compared with only 5 errors reported during the previous year through a traditional incident-reporting system. Reports there originated from physicians (45%), nurses (41%), other staff (9%), and parents/patients (5%). Errors were classified as involving office administration (34%), medications and other treatment (24%), laboratory and diagnostic testing (19%), and communications (18%). None was assessed to cause significant patient harm.10
Although our project and the 2 previous studies that used a similar model were all performed in academic settings, a similar project is implementable in a nonacademic, private-practice setting. The key elements of this model—fostering a nonpunitive response to errors, collecting anonymous reports, analyzing reported errors with a multidisciplinary team, and enacting changes to reduce such errors—are all realistic to attempt in a variety of pediatric practice settings.
Our study had several limitations. Errors were reported voluntarily in a busy practice, so it is likely that many errors were undetected and/or unreported. Results of previous studies have suggested that medication errors alone occur in 15% to 26% of pediatric outpatient visits.14,19,–,21 Many medication errors originate in outside pharmacies or faulty home administration and may remain unknown to prescribers. Reporter anonymity was essential for promoting reporting but sometimes limited the team's ability to fully investigate root causes. A remaining challenge is to determine if our practice is safer as a result of this project, which would include assessing safety culture among our staff.22
Further studies are needed to enhance our understanding of the types of medical errors that occur in ambulatory practices. Knowledge about the effectiveness of interventions to reduce patient harm in these settings is of utmost importance. More active involvement of parents in error reporting might help detect medication errors and other medical mishaps to aid in designing safer care systems.
Team members Susan Jordan, RN, Yolanda Sims, Anna Chong, MD, Monica Henson, Diann Moore, Debbie Weaver, PNP, and Dishandra Mathis made invaluable contributions to this project. Cheryl Courtlandt, MD assisted with the control chart.
- Accepted August 14, 2011.
- Address correspondence to Daniel R. Neuspiel, MD, MPH, Levine Children's Hospital, 1350 South Kings Dr, Charlotte, NC 28207. E-mail:
Each author has made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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- Copyright © 2011 by the American Academy of Pediatrics