Health Department Establishes a Voluntary "Near-Miss" Hospital Event Reporting System With American College of Physicians

ALBANY, N.Y. (Nov. 13, 2007) – The state Health Department and the New York chapter of the American College of Physicians have agreed to analyze "near-misses" in New York hospitals – events that could have harmed a patient, but did not – to help prevent medical errors.

In a three-year demonstration program, the Health Department's Patient Safety Center will work with doctors-in-training in internal medicine to confidentially collect and analyze "near-misses" to help hospitals build safer health care systems to protect patients. This new system will complement New York's mandatory adverse event reporting system, New York Patient Occurrence Reporting and Tracking System (NYPORTS), which already collects information on serious injuries and deaths in hospitals.

More than 4,700 medical residents will volunteer to report their "near-miss" events. The Health Department expects that the pool of eligible reporters will be expanded at the end of the demonstration program. The project will be supervised by John Morley, M.D., Medical Director of the Department's Office of Health Systems Management, and Ethan Fried, M.D., Residency Program Director in Internal Medicine at St. Luke's -Roosevelt Hospital Center.

"We now have the means by which physicians, hospitals and government can collect accurate information, make improvements designed on that information and then follow up those changes to confirm that care is (or is not) safer," Dr. Morley explained. "The improvements we need in health care can only be achieved through working together. The quality cycle of Plan, Do, Study, Act, or PDSA, is the path to improvement." PDSA, also known as PDCA (Plan, Do, Check, Act), is a process commonly used in the quality improvement industry. A problem is identified, a solution is planned and implemented on a very small scale to confirm or refute the theory. If the solution works on a small scale, it can be implemented system-wide.

Stephen Peterson, M.D., FACP, President of the New York chapter of the American College of Physicians, said, "We are proud of the steps taken by the New York chapter of the American College of Physicians to improve patient safety, and we are grateful to the many groups who are committed to collaborating to make this project a success."

DOH and the NYACP have established an Advisory Committee of experts on patient safety, quality and education that will aid the collaboration to make best use of the data collected.

"The New York State Department of Health and the New York Chapter of the American College of Physicians are to be congratulated for creating this new partnership promoting better quality and safer medical care", said Harvey V. Fineberg, M.D., President of the Institute of Medicine. "Every one of us can learn from the results of the innovative reporting program they are undertaking."

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