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Patient Safety and Quality

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Hospital incident reporting systems often miss physician high-risk procedure and prescribing errors

U.S. hospitals have long had voluntary incident reporting systems to report medication errors, falls, patient misidentification, retained foreign bodies after surgery, and other incidents. Nurses report most of these incidents, while physicians report very few. As a result, few physician incidents involving high-risk procedures or prescribing errors get reported, according to a new study. Yet, these incidents are usually responsible for most adverse events, according to a study by University of California Los Angeles researchers. The researchers examined a representative sample of 1,000 incident reports of hospitalized patients at one academic and one community hospital in 2001.

Overall, 9 percent of patients and 8 percent of hospitalizations prompted at least one incident report. Nurses filed 89 percent of the reports, physicians 1.9 percent, and other providers 8.9 percent. Nearly 60 percent of incidents were preventable, and non-physician providers seemed to be involved in most of them.

Other studies have shown that most adverse events occurred in operating rooms, floor units, and intensive care units. Yet, the reporting system in this study identified more falls, drug administration errors, and miscellaneous events occurring in patient rooms, and far fewer incidents involving surgery. Also, only a handful of incident reports involved high-risk procedures such as endoscopy, bronchoscopy, or central line placement.

The fact that only 16 percent of the reports in this study addressed physician care represents a major limitation of hospital reporting systems. Incident reports probably underemphasize physician care for two reasons. First, they were developed to minimize litigation against hospitals and their employees. Second, physicians are probably better than other providers at identifying physician errors, and physician reporting is minimal. Shifting the purpose of reporting from preventing litigation against hospitals to improving safety would make capturing physician incidents a higher priority. However, incident reports can be disclosed in litigation in some States.

The study was funded in part by the Agency for Healthcare Research and Quality (HS11512).

See "Rates and types of events reported to established incident reporting systems in two U.S. hospitals," by Teryl K. Nuckols, M.D., Douglas S. Bell, M.D., Honghu Liu, Ph.D., and others, in the June 2007 Quality & Safety in Health Care 16, pp. 164-168.

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