Error Reporting Systems

  • David C. Stockwell
  • Anthony D. Slonim
Part of the Health Informatics book series (HI)


The ability to detect errors in medicine is an important starting point for programmatic interventions aimed at improving patient safety. While information technology has the ability to improve many aspects of healthcare, the optimization of error reporting can ultimately improve error reduction because of the focus it brings to system defects.


Medical Error Adverse Drug Event Incident Report Vaccine Adverse Event Reporting System Pediatr Crit 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Institute of Medicine Committee on Quality of Health Care in America. To Err is Human Building a Safer Health System. Washington, DC: National Academy Press; 2000.Google Scholar
  2. 2.
    Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.Google Scholar
  3. 3.
    Lohr KN, ed. Medicare: A Strategy for Quality Assurance. Washington, DC: National Academy Press; 1990.Google Scholar
  4. 4.
    US Department of Health and Human Serrvices. Hospital Compare; 2008. Available at: Accessed December 21, 2008.
  5. 5.
    Cincinnati Children's Hospital Medical Center. How Cincinniati Children's Measures Up; 2008. Available at: Accessed December 21, 2008.
  6. 6.
    Stockwell DC, Slonim AD, Pollack MM. Physician team management affects goal achievement in the intensive care unit. Pediatr Crit Care Med. 2007;8(6):540–545.PubMedCrossRefGoogle Scholar
  7. 7.
    Skiba M. Strategies for identifying and minimizing medication errors in health care settings. Health Care Manag. 2006;25:70–77.Google Scholar
  8. 8.
    Pronovost PJ, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin. 2005;21(1):1–19, vii.PubMedCrossRefGoogle Scholar
  9. 9.
    McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–2645.PubMedCrossRefGoogle Scholar
  10. 10.
    Slonim AD, Pollack MM. Integrating the Institute of Medicine's six quality aims into pediatric critical care: relevance and applications. Pediatric Crit Care Med. 2005;6:264–269.CrossRefGoogle Scholar
  11. 11.
    Bates DW, Evans RS, Murff H, et al. Detecting adverse events using information technology. J Am Med Inform Assoc. 2003;10(2):115–128.PubMedCrossRefGoogle Scholar
  12. 12.
    Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug event: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21:541–548.PubMedGoogle Scholar
  13. 13.
    Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics. 2004;114:729–735.PubMedCrossRefGoogle Scholar
  14. 14.
    Buckley MS, Erstad BL, Kopp BJ, et al. Direct observation approach for deteching medication errors and adverse drug events in a pediatric intensive care unit. Pediatr Crit Care Med. 2007;8(2):145–152.PubMedCrossRefGoogle Scholar
  15. 15.
    Stockwell DC, Slonim AD. Detecting medication errors: a job for six sigma. Pediatr Crit Care Med. 2007;8(2):190–192.PubMedCrossRefGoogle Scholar
  16. 16.
    Friedman JN, Pinard MS, Laxer RM. The morbidity and mortality conference in university-affiliated pediatric departments in Canada. J Pediatr. 2005;146:1–2.PubMedCrossRefGoogle Scholar
  17. 17.
    Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA. 2006;296:696–699.PubMedCrossRefGoogle Scholar
  18. 18.
    Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140:1025–1033.PubMedGoogle Scholar
  19. 19.
    Wears RL, Janiak B, Moorhead JC, et al. Human error in medicine: promise and pitfalls, part 2. Ann Emerg Med. 2000;36:142–144.PubMedCrossRefGoogle Scholar
  20. 20.
    Joint Commission. Medical Errors, Sentinel Events, and Accreditation. A report to the Association of Anesthesia Program Directors.Google Scholar
  21. 21.
    Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35–43.PubMedCrossRefGoogle Scholar
  22. 22.
    Roos NP, Black CD, Roos LL, et al. A population-based approach to monitoring adverse outcomes of medical care. Med Care. 1995;33:127–138.PubMedCrossRefGoogle Scholar
  23. 23.
    Vicente K. The Human Factor: Revolutionizing the Way People Live with Technology. New York: Routledge.Google Scholar
  24. 24.
    Miller MR, Clark JS, Lehmann CU. Computer based medication error reporting: insights and implications. Qual Saf Health Care. 2006;15(3):208–213.PubMedCrossRefGoogle Scholar
  25. 25.
    University Health System Consortium. Patient Safety Net (PSN), Learn More; 2008. Available at: Accessed December 21, 2008.
  26. 26.
    US Pharmacopeia. MEDMARX National Database Website; 2008. Available at: https://www. Accessed December 21, 2008.
  27. 27.
    US Food and Drug Administration. MedWatch Website; 2008. Available at: http://www.fda. gov/medwatch/. Accessed December 21, 2008.
  28. 28.
    US Department of Health and Human Services (DHHS). VAERS - The Vaccine Adverse Event Reporting System Website; 2008. Available at: Accessed December 21, 2008.
  29. 29.
    US Food and Drug Administration. Center for Biologics Evaluation and Research (CBER) Website: Blood; 2008. Available at: Accessed December 21, 2008.
  30. 30.
    Medical Event Reporting System - Transfusion Medicine (MERS-TM); 2008. Available at: Accessed December 21, 2008.
  31. 31.
    Slonim AD, LaFleur BJ, Ahmed W, et al. Hospital-reported medical errors in children. Pediatrics. 2003;111(3):617–621.PubMedCrossRefGoogle Scholar
  32. 32.
    Honigman B, Lee J, Rothschild J, et al. Using computerized data to identify adverse drug events in outpatients. J Am Med Inform Assoc. 2001;8(3):254–266.PubMedGoogle Scholar
  33. 33.
    Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: a practical methodology for measuring medication related harm. Qual Saf Health Care. 2003;12:194–200.PubMedCrossRefGoogle Scholar
  34. 34.
    Resar RK, Rozich JD, Simmonds T, et al. A trigger tool to identify adverse events in the intensive care unit. Jt Comm J Qual Patient Saf. 2006;32(10):585–590.PubMedGoogle Scholar
  35. 35.
    Jha A, Kuperman G, Teich J, et al. Identifying adverse drug events: development of a computer- based monitor and comparison with chart review and stimulated voluntary report. JAMIA. 1998;5(3):305–314.PubMedGoogle Scholar
  36. 36.
    Melton GB, Hripcsak G. Automated detection of adverse events using natural language processing of discharge summaries. J Am Med Inform Assoc. 2005;12(4):448–457.PubMedCrossRefGoogle Scholar
  37. 37.
    Sharek PJ, Horbar JD, Mason W, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006;118: 4:1332–1340.CrossRefGoogle Scholar
  38. 38.
    Field TS, Gurwitz JH, Harrold LR, et al. Strategies for detecting adverse drug events among older persons in the ambulatory setting. J Am Med Inform Assoc. 2004;11(6):492–498.PubMedCrossRefGoogle Scholar
  39. 39.
    Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic screening algorithm. Archives of Internal Medicine. 2007;167(3):302–308.PubMedCrossRefGoogle Scholar
  40. 40.
    Marx D. Patient Safety and the ‘Just Culture ’: A Primer for Health Care Executives. New York: Columbia University; 2001. Available at: Primer.pdf. Accessed December 21, 2008.Google Scholar
  41. 41.
    Wachter RM. The end of the beginning: patient safety five years after ‘to err is human’. Health Aff (Millwood); 2004: Suppl W4–534–45. Available at: Accessed December 2008.
  42. 42.
    Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2006;15;184(10 Suppl):S65–S68.Google Scholar
  43. 43.
    Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics. 2008;121(4):e927–e935.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • David C. Stockwell
    • 1
  • Anthony D. Slonim
    • 2
    • 3
  1. 1.Children's National Medical CenterWashington
  2. 2.Carilion Medical CenterRoanoke
  3. 3.Pediatrics and Public HealthUniversity of Virginia School of MedicineCharlottesville

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