Value of Voluntary Intranet-based Medical Error Reporting System

Kang, Min Uk; Kim, Jae Kwang; Lim, Yong Su; Kim, Jin Joo; Hyun, Sung Youl; Yang, Hyuk Jun; Lee, Gun; Kwon, Ji Won; Jo, Jin Sung

Abstract

PURPOSE
The emergency department is prone to medical errors due to the patients'acuity and complexity. Collection and monitoring of data on medical errors are essential for setting priorities and improving patient safety.
METHODS
Emergency physicians report medical errors voluntarily with an intranet-based error reporting system. The system is confidential and anonymous. Data on medical errors was collected at the emergency department of a tertiary teaching hospital with approximately 76,000 annual visits, during a nine-month period from April to December 2008. The collected data was analyzed prospectively.
RESULTS
Of the 238 reports collected, 204 errors were analyzed. 90.6% of the errors were related to doctors and 21% were related to nurses. Error types were classified into clinical errors (57%), medication errors (7%) and administrative errors (35%). The levels of impact on patients caused by these errors were classified as near-miss in 28 (13%), no harm in 93 (45%), mild harm in 66 (32%), lethal in 5 (2%) and death in 2 (1%) cases. Errors that occurred in the elderly group (over 60 years of age) had more harmful impact than in other age groups (p=0.0003). The causes of these errors were human in 147 (72%), systems in 23 (11%) and both human and systems in 34 (17%). Most of these errors were preventable (99%).
CONCLUSION
Data collected by the intranet-based medical error reporting system is useful to classify and analyze medical errors, and is also essential in the implementation of a patient safety system.