Reports From the Field

Improved Safety Event Reporting in Outpatient, Nonacademic Practices with an Anonymous, Nonpunitive Approach

Journal of Clinical Outcomes Management. 2015 February;22(2)

Author(s):

Herbert W. Clegg II, MD

Terri Cardwell, RPh, PharmD, MHA

Aaron M. West, BS

Felicia Ferrell, BA

References

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From Novant Health and Novant Health Medical Group, Winston-Salem, NC.

Abstract

Objective: To evaluate the effect of an educational intervention with regular audit and feedback on reporting of patient safety events in a nonacademic, community practice setting with an established reporting system.
Methods: A quasi-experimental with comparator design was used to compare a 6-practice collaborative group with a 27-practice comparator group with regard to safety event reporting rates. Baseline data were collected for a 12-month period followed by recruitment of 6 practices (3 family medicine, 2 pediatric, and 1 general surgery). An educational intervention was carried out with each, and this was followed by monthly audit and regular written and in-person feedback. Practice-level comparisons were made with specialty- and size-matched practices for the 6 practices in the collaborative group.
Results: In the 12-month period following the intervention in March 2013, the 6 practices reported 175 patient safety events compared with only 19 events in the previous 12-month period. Each practice at least doubled reporting rates, and 5 of the 6 significantly increased rates. In contrast, rates for comparator practices were unchanged, with 84 events reported for the pre-intervention period and 81 for the post-intervention period. Event classification and types of events reported were different in the collaborative practices compared with the comparators for the post-intervention period. For the collaborative group, near miss events predominated as did diagnostic testing and communication event types.
Conclusion: An initial educational session stressing anonymous, voluntary safety event reporting together with monthly audit and feedback and a focus on developing a nonpunitive environment can significantly enhance reporting of safety events.

Multiple challenges in the outpatient setting make establishing a culture of safety and improving care delivery more difficult than for inpatient settings. In the outpatient setting, care is often inaccessible, not well coordinated between providers and between facilities and providers, and delivered in many locations. It may also involve multiple sites and providers for a single patient, may require multiple visits in a single location, and can be provided by phone, email, mail, video, or in person [1]. Errors and adverse events may take long periods of time to become apparent and are more often errors of omission compared with those in the inpatient setting [2].

Incident reporting systems are considered important in improving patient safety [3], and their limitations and value have recently been reviewed [4]. However, limited research has been conducted on medical errors in ambulatory care, and even less is available on optimal monitoring and reporting strategies [5–12].Reporting in our system is time-consuming (about 15 minutes for entry of a single report), is not tailored for outpatient practices, may be considered potentially punitive (staff may believe that reporting may place themselves at risk for performance downgrade or other actions), and marked under-reporting of safety events was suspected. Most but not all of the suggested characteristics considered important for hospital-based reporting systems are fulfilled in our ambulatory reporting system [13].

Several academic groups have reported much improved reporting and a much better understanding of the types of errors occurring in their respective outpatient settings [14–16]. The most compelling model includes a voluntary, nonpunitive, anonymous reporting approach and a multidisciplinary practice-specific team to analyze reported errors and to enact change through a continuous quality improvement process [14,15].