Improving Error Reporting in Ambulatory Pediatrics with a Team Approach

Objective: We aimed to determine the effectiveness of team-based reporting, systems analysis, and redesign to address medical errors in pediatric ambulatory care. Methods: Voluntary, anonymous, nonpunitive reporting, paired with a team-based system analysis and change implementation, was established in an outpatient pediatric department of an urban teaching hospital. Results: In the first year, 80 errors were reported, compared with only 5 errors reported during the prior year via a traditional incident reporting system. Reports originated from physicians (45 percent), nurses (41 percent), other staff (9 percent), and parents/patients (5 percent). Errors were classified as involving office administration (34 percent), medications and other treatment (24 percent), laboratory and diagnostic testing (19 percent), and communications (18 percent). To date, 65 percent of reports have resulted in completed interventions, and other changes are in progress. Conclusion: In an academic pediatric ambulatory practice, voluntary, nonpunitive reporting with team-based systems analysis and rapid redesign improved error reporting and resulted in changes to promote safety.