Regional Ambulatory Near Miss Reporting and Tracking to Improve Patient Safety (H

描述（由申请人提供）：在没有对患者造成实际伤害的情况下，侥幸事件代表了一个低风险的机会，可以提高患者的安全性，并解决患者对医疗保健风险的期望，这两个因素都与医疗事故诉讼和赔偿有关。医学研究所（IOM）呼吁建立自愿报告系统，以检测个别卫生保健组织中发生的未遂事件，并允许分析可能影响许多或所有保健提供者的错误模式。迄今为止，在美国，大多数记录和处理未遂事件的尝试都是在医院进行的。需要更广泛的系统开发和评估，以有效地将未遂报告扩展到非医院环境。这项规划赠款将启动一项研究，该研究将是第一批在广泛的初级保健环境中提出和评估“侥幸报告”系统的研究之一。主要目标是更好地了解在初级保健中实施未遂报告和改进跟踪系统的障碍、促进因素和结果。第二个目标是探索利用险些事故事件来提高提供者对患者错误披露的信心和经验的可能性，以及在发生有害医疗事件时，这种披露是否会降低患者寻求法律咨询和提出医疗事故索赔的可能性。北卡罗莱纳州农村卫生和社区保健办公室（ORHCC）提议对未遂事件报告和改进跟踪系统进行初步研究。未遂报告和跟踪系统将被引入6个不同的实践参与区域流动实践网络。干预有三个组成部分：1)每个实践的标准化方向；2)报告和收集六个月的每次实践的未遂事件报告，以及3)持续的教育和质量改进工作，旨在理解和从未遂事件中学习，包括持续的员工提示和提醒他们使用该系统。本研究的研究方面包括：a)评价系统在六个研究实践中的实施情况；B)对报告的未遂事件类型的分析，包括其相关性和严重性评级的有效性；c)评估患者和提供者报告的关于险些泄露影响的行为。作为这项初步研究的结果，研究小组希望更好地了解如何在初级保健环境中实施未遂事件报告系统，实践如何响应未遂事件报告（例如，哪种类型的事件可能最适合改进），如何增加对未遂事件的认识与提供者对患者安全的意识和态度以及实践变化有关。以及提供者的信息披露如何影响患者寻求法律建议的行为。

DESCRIPTION (provided by applicant): Near-miss events, where no actual harm comes to the patient, represent a low-risk opportunity to improve patient safety and address patient expectations about medical care risks, both factors associated with medical malpractice suits and awards. The Institute of Medicine (IOM) has called for the creation of voluntary reporting systems to detect near-miss events that occur in individual health care organizations, and to allow for analysis of patterns of errors that may affect many or all providers of care. To date, most attempts to record and address near-miss events in the United States have been conducted in hospitals. More extensive system development and evaluation are needed to effectively extend near-miss reporting to non-hospital settings. This planning grant will initiate a study that will be among the first to present and evaluate a near-miss reporting system in a broad range of primary care settings. The primary goal is to better understand the barriers, facilitators, and results of implementing a near-miss reporting and improvement tracking system in primary care. The secondary goal is to explore the potential of using near-miss events to increase provider confidence and experience with error disclosure to patients, and whether such disclosure decreases the likelihood that patients will seek legal advice and file malpractice claims in the event of a harmful medical event. The North Carolina Office of Rural Health and Community Care (ORHCC) proposes to conduct a preliminary study of a near-miss reporting and improvement tracking system. The near-miss reporting and tracking system will be introduced into six diverse practices participating in a regional ambulatory practice network. The intervention has three components: 1) a standardized orientation for each practice; 2) reporting and collection of near-miss reports from each practice for six months, and 3) ongoing educational and quality improvement efforts aimed at understanding and learning from the near-miss events including ongoing staff prompts and reminders to use the system. Research aspects of the study include: a) evaluation of the implementation of the system in the six study practices; b) analysis of the types of near-miss events reported including their correlates and the validity of seriousness ratings; and c) evaluation of patient and provider reported behaviors regarding the influence of near-miss disclosure. As a result of this preliminary study, the research team expects to gain a better understanding about how to implement a near-miss reporting system in primary care settings, how practices respond to near-miss event reporting (e.g., which types of events may be most amenable to improvement), how increased recognition of near-miss events relates to provider awareness and attitudes toward patient safety and practice change, and how provider disclosure might influence patient behavior in terms of seeking legal advice. PUBLIC HEALTH RELEVANCE: Rising malpractice and health care costs make efforts to improve patient safety in the primary care setting both timely and important. Near-miss events, which have the potential to lead to patient harm but harm is averted, represent a significant opportunity to correct flaws that create risks to patient safety, yet few near-miss reporting systems exist outside of hospital settings. Through implementation and evaluation of a near-miss reporting and remediation tracking system in six primary care practices, this preliminary study will lead to better understanding of how practices respond to near-miss reporting (e.g., which types of events may be most amenable to improvement), how increased recognition of near-miss events relates to provider attitudes toward patient safety and practice change, and how provider disclosure of near-misses might influence patient behavior in terms of seeking legal advice.