Abstract
Hospital medical errors that result in patient harm and death are largely identified as system failures. Most hospitals lack the tools to effectively identify most system errors. Traditional methods used in many hospitals, such as incident reporting (IR), departmental morbidity and mortality conferences, and root cause analysis committees, are often flawed by under reporting. We introduced the Code S designation into our hospital's ongoing physician peer review process as an additional and innovative way to identify system errors that contributed to adverse clinical outcomes. The authors conducted a retrospective review of all peer review cases from January 2008 to December 2011 and determined the quantity and type of system errors that occurred. System errors were categorized based on a modified 5M model which was adapted to reflect system errors encountered in healthcare. The Code S designation discovered 204 system errors that otherwise may not have previously been identified. The addition of the Code S designation to the peer review process can be readily adopted by other healthcare organizations as another tool to help identify, quantify and categorize system errors, and promote hospital-wide process improvements to decrease errors and improve patient safety.
Highlights
Medical errors commonly occur in the hospital setting and result in patient harm and even death [1,2,3]
Hospitals have implemented the use of incident reporting (IR) systems to help identify patient safety risks related to system errors
Hospital-wide physician peer review processes already exist in hospitals to track provider performances; they are not routinely used to identify hospital system errors that contribute significantly to adverse patient outcomes or create potential risks for future events
Summary
Medical errors commonly occur in the hospital setting and result in patient harm and even death [1,2,3]. A large majority of medical errors resulting in patient harm are related to system failures, and not from individual errors or negligence [5,6,7,8]. Developed by the medical profession to review the qualifications and practice patterns of medical staff physicians [9,10], physician peer review can be used to identify system errors that may contribute to adverse clinical outcomes [11,12]. Given the significant negative impact of system-related medical errors on patient safety, many healthcare organizations have established medical error reduction as a priority. This has strengthened the case for developing a systematic process to recognize and subsequently prevent system-related medical errors. The Joint Commission (TJC) maintains that meaningful improvements in patient safety are dependent on each organization’s ability to identify errors and analyze their contributing factors to prevent similar errors from recurring [8]
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