Implementation of a Data-Based Medical Event Reporting System in the U.S. Department of Defense

As a result of the Institute of Medicine (IOM) report, To Err Is Human, the Department of Defense (DoD), per the direction of President Clinton, developed an action plan to reduce medical errors. A system to track and trend near misses and adverse safety events for all the medical treatment facilities in the DoD was developed. A standard spreadsheet for data collection through e-mail was created and implemented. A relational database management system was utilized for data analysis. The data reporting system is a qualified success. There are limitations with statistical analysis and variations in the data submitted. The system has helped to identify patterns of patient safety errors and areas where patient safety events warrant further investigation. Published in Advances in Patient Safety: From Research to Implementation, v3 p235-244, AHRQ Publication Nos. 050021 (1-4), Feb 2005. Prepared in cooperation with Department of Defense Patient Safety Center.