PA PSRS Patient Saf Advis 2006 Sep;3(3):15.
Getting Doctors to Report Medical Errors

Editor’s Note

This article was abstracted from: King E, Moyer D, and  Couturie M, et al. Getting doctors to report medical errors: Journal on Quality and Patient Safety 2006; 32(7):382-92.

Study

A recent study at Temple University Hospital in Philadelphia significantly boosted physician compliance with adverse event and near miss reporting requirements. During the three-month study period, physicians submitted 2.6 times as many reports using this new model as they submitted through the hospital’s traditional reporting system.

This new physician reporting model – called DISCLOSE* addressed many of the barriers to physician reporting such as:

  • Incident form location
  • Lengthy questions
  • Obtaining multiple signatures
  • Uncertainty about what is reportable
  • Dissatisfaction with lack of closure or feedback

Participating physicians were given a simplified paper-based report form that could fit in their pockets, making it easy to incorporate them into daily patient rounds. They could submit reports at multiple locations throughout the hospital.

During the study, participants were asked to provide detailed narrative information regarding the incident on both the DISCLOSE form and on the traditional hospital report form. Those events reported with the DISCLOSE tool that qualified as a sentinel event were brought to the attention of risk management and forwarded to the proper committees. The narrative portions of all reports were analyzed, and some incidents were recategorized to conform as much as possible.

Physicians who used the DISCLOSE tool seemed much more willing to report all events from minor to life-threatening. Where improvements were needed with staff, physicians were encouraged to address staff related incidents with department heads. Staff-related events and patient transport problems were the most frequently reported categories. Drug related events and communication errors were also commonly reported.

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* This acronym stands for:

D — Drugs
I — Iatrogenic complications
S — System errors
C — Communication errors
L — Lab and test issues
O — Oversights
S — Staffing issues
E — Equipment issues

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