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The fact that medical errors and near-misses are under-reported is well documented. Although there is little research that examines patterns of reporting in ambulatory care, we recognized that the small number of events reported by the nearly fifty ambulatory care practices in our health system were likely an indication that our ambulatory colleagues were not recognizing and/or not reporting medical mishaps, process or system lapses, and near-misses consistently. Barriers to recognizing and reporting events were identified using several methods. As the research on event reporting predicted, the most fruitful method to gather this information was through discussions with colleagues in each of the practices. Using the gathered information, strategies were designed and in the fall of 2017, implemented to breakdown the identified barriers.
There were 153 events reported by the ambulatory practices in 2016. In 2017, there were 365 reported events, of which nearly 40% were submitted in the last quarter of the year. The trend in 2018 is higher and has been sustained throughout the year. In addition to data on trends in reporting, this poster will include how our team: (1) identified barriers to reporting events, (2) designed and implemented strategies to reduce those barriers, and (3) engaged staff to achieve and sustain consistent reporting of events. Emphasis will be placed on the importance of empowering staff to participate in identification of opportunities for improvement throughout ambulatory care practices.
