The Impact of a Patient Safety Program on Medical Error Reporting

Background: In response to the occurrence of a sentinel event—a medical error with serious consequences—Eglin U.S. Air Force (USAF) Regional Hospital developed and implemented a patient safety program called Medical Team Management (MTM) that was modeled on the aviation industry’s Crew Resource Management program and focused on communication, teamwork, and reporting. Objective: To determine the impact of a patient safety program on patterns of medical error reporting. Methods: This study was a retrospective review of 1,102 incident reports filed at Eglin USAF Regional Hospital in Florida between 1997 and 2001. Collected data from the comparison periods (1998 and 2001) was statistically analyzed using the chi-square test. Results: The number of reports submitted increased significantly from 200 for 4,671 hospital admissions in 1998 to 276 for 4,003 admissions in 2001 (chi-squared = 28.38, P < 0.0001). Evaluation of incident severity showed 172 (86 percent) near misses (no impact on patient) in 1998 and 251 (91 percent) in 2001. In 1998 there were 28 (14 percent) adverse events (patient minimally effected) and 25 (9 percent) in 2001 (chi-squared = 3.302, P = 0.069). Analysis by rank of person filing the report revealed 39 reports submitted by junior nurses and 11 submitted by junior enlisted personnel in 1998, while in 2001 those numbers increased to 75 and 24 reports, respectively (chi-squared = 6.554, P = 0.161). Conclusion: This study indicates that, since the implementation of MTM, there has been a statistically significant increase in the number of reports filed at Eglin USAF Regional Hospital. Similarly, the severity of incidents shows an overall decline approaching statistical significance. Although there was an increase in reporting from junior team members, this was not statistically significant. These findings suggest that there have been changes in the patterns of error reporting since the implementation of MTM.