Abstract
Voluntary medical incident reporting systems are a valuable source for studying adverse events and near misses. Unfortunately, such systems usually contain a large amount of incomplete and inaccurate reports which negatively affect their utility for medical error research. To investigate the reporting quality and propose solutions towards quality voluntary reports, we employed a content analysis method to examine one-year voluntary medical incident reports of a University Hospital. Results indicate that there is a large amount of inconsistent records within the reports. About 25% of the reports were labeled as “miscellaneous” and “other”. Through an in-depth analysis, those “miscellaneous” and “other” were substituted by their real incident types or error descriptions. Analysis shows that the pre-defined reporting categories serve well in general for the voluntary reporting need. In some cases, human factors play a key role in selecting accurate categories since reporters lack time or information to complete the report. We suggest that a human-centered, ontology based system design for voluntary reporting is feasible. Such a design could help improve the completeness and accuracy, and interoperability among national and international standards.
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Acknowledgements
This project is supported in part by a grant (URC-08-023) awarded by the Research Council of University of Missouri-Columbia, by Richard Wallace Research Incentive Grant Award, and by the Center for Health Care Quality of University of Missouri Health Care. The author expresses heartfelt thanks to Zhijian Luan, James Richardson, Patricia Alafaireet and Illhoi Yoo who assisted in de-identifying and analyzing data in early stages. A special thank goes to two anonymous reviewers who offered invaluable constructive comments for an early draft.
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Gong, Y. Data Consistency in a Voluntary Medical Incident Reporting System. J Med Syst 35, 609–615 (2011). https://doi.org/10.1007/s10916-009-9398-y
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DOI: https://doi.org/10.1007/s10916-009-9398-y