Pediatric Informatics: Computer Applications in Child Health (Health ...

30 Error Reporting Systems 391
this approach. Admission of mistakes in medicine is not part of the cultural norm.
Concern over liability and public disclosure and how that may affect recruitment of
patients minimize the open disclosure.
30.5.1 Electronic Incident Reporting
Some institutions have developed internal electronic anonymous reporting systems.
Having one institutional model may help to increase participation and reduce
confusion and frustration with the submission process. The reporter completing
the online form also benefits from true anonymity. Finally, if the process is well
designed and submission of these forms is not overly laborious then near-miss and
adverse event collection may increase. 24
Limitations of electronic incident reporting parallel those of their paper equivalents.
Electronic reporting may increase the number of submitted reports, but the
reporting bias associated with a large fraction of errors and near misses that are not
gathered is a major problem. Also while the reporting may be improved the real
benefits of incident reports are not the reports themselves but as a way to identify
the problems within the healthcare environment and act on them. Inaction after the
report is submitted will stifle improvement. Finally lack of coordinated reporting
does not allow for learning from other hospitals that have benefited from learning
from their own mistakes and then making their experiences public.
Recently several Web-accessible, anonymous error reporting programs designed
for hospitals and health systems to systematically collect, analyze, and report medication
errors have been created. Academic systems have developed confidential,
voluntary error reporting systems at the organizational level. Patient Safety Net
was developed by the University HealthSystem Consortium, a coalition of 87 academic
medical centers. The Patient Safety Net is a software program and database,
accessible via the Internet, for “Safety Report” entry by health care workers and
clinicians. 25 Large healthcare systems can streamline the approach to incident
reporting, identify trends within their own institutions and ensure action on the
identified errors.
The United States Pharmacopeia is the official public standards-setting authority
for all prescription and over-the-counter medicines, dietary supplements, and
other healthcare products manufactured and sold in the United States. United
States Pharmacopeia sets standards for the quality of these products and works
with healthcare providers to help them reach the standards. They have created a
subscription based national, Internet-accessible database that hospitals and health
care systems use to track and trend adverse drug reactions and medication errors.
Hospitals and health care systems participate in this system called MEDMARX
voluntarily and subscribe to it on an annual basis. MEDMARX is a quality
improvement tool, which facilitates productive and efficient documentation, reporting,
analysis, tracking, trending, and prevention of adverse drug events. Individual
hospitals can compare their own data to the database and allow for benchmarking.