Design elements for a primary care medical error reporting system.

Abstract

PROBLEM CONSIDERED: State and federal initiatives to develop medical error reporting systems are being proposed. For these to lead to an effective error reporting system to improve primary care, the needs of primary care professionals must be understood. METHODS: This study was based on the answers to key questions directed at primary care physicians and clinical assistants. A series of focus groups was held to determine what elements need to be included in the design of a medical error reporting system for ambulatory care. RESULTS: Participants addressed the purposes of an error reporting system, the barriers and motivators to the use of a system, the types of events that should be reported, how the reporting should be done, and how the data should be analyzed and used. During the sessions, 87 different themes emerged that were distilled down to the general principles and operating design elements deemed most important. CONCLUSIONS: The participating physicians and clinical assistants supported a primary care medical error reporting system designed to provide useful information to improve health care. The system should not be punitive.