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Voluntary Error-Reporting System Ensures Patient Safety

According to a study by the investigators at John Hopkins Children’s Center//, patient’s safety system can be improved by reporting as well as recording the medication errors into a computer database.

Hopkins researchers said ‘Human error rates are minimized by identifying, fixing and reporting on the errors voluntarily plus steps taken to overcome it in the future’.

Voluntary error-reporting systems are not new, but few studies have looked at the accuracy of the reporting and its impact, the Hopkins investigators say.

‘Our goal was to explore the validity of this voluntary error-reporting system and whether front-line error-reporters were capturing the essence of the actual errors that occurred,’ says author Marlene Miller, M.D., M.Sc., director of quality and safety initiatives for the Children’s Center. ‘There were some incorrect reports, but the overall trends were accurate, which allows us to say that this reporting system is a reliable index of problematic areas.’ The findings are reported in the June issue of Quality & Safety in Healthcare.

Miller emphasizes that error data are valuable only if consistently monitored for patterns and used to create safety checks that prevent common errors from happening again.

‘Error reporting is only as good as the actual changes that are made as a result of it,’ says co-author Christoph Lehmann, M.D., director of clinical information technology at the Children’s Center. ‘Identifying and fixing potential medical errors is at the core of the Children’s Center patient safety program. Monitoring voluntary error reports has led to the creation of several programs that reduce and prevent medication errors.’

Among these:

? A computerized ordering tool for pediatric chemotherapy that reduces medication errors in children undergoing cancer treatment (for more information, see http://www.hopkinschildrens.org/pages/news/pressdetails.cfm?newsid=340)

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