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Jt Comm J Qual Patient Saf. 2006 Jul;32(7):382-92.

Getting doctors to report medical errors: project DISCLOSE.

Author information

1
Department of Internal Medicine, Temple University Hospital, Temple University School of Medicine, Philadelphia, USA.

Abstract

BACKGROUND:

Despite the number of patient safety incidents that occur in hospitals, physicians currently may not have the ideal incident reporting tools for easy disclosure. A study was undertaken to assess the effectiveness of a simplified paper incident reporting process for internal medicine physicians on uncovering patient safety incidents.

DESIGN:

Thirty-nine internal medicine attending physicians were instructed to incorporate the use of a simplified paper incident reporting tool (DISCLOSE) into daily patient rounds during a three-month period. All physicians were surveyed at the conclusion of the three months.

RESULTS:

Compared with physician reporting via the hospital's traditional incident reports from the same time period, a higher number (98 incidents versus 37; a 2.6-fold increase) of incidents were uncovered using the DISCLOSE reporting tool in a larger number of error categories (58 versus 14, a 4.1-fold increase). When reviewed and classified with a five-point harm scale, 41% of events were judged to have reached patients but not caused harm, 33% to have resulted in temporary harm, and 9% of reports, though not considered events, were to indicate a "risky situation." Surveyed physicians were more satisfied with the process of submitting incident reports using the new DISCLOSE tool.

DISCUSSION:

A simplified incident reporting process at the point of care generated a larger number and breadth of physician disclosed error categories, and increased physician satisfaction with the process.

PMID:
16884125
DOI:
10.1016/s1553-7250(06)32050-8
[Indexed for MEDLINE]

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