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Qual Saf Health Care 17:307-312 doi:10.1136/qshc.2006.018440
  • Error management

“Every error counts”: a web-based incident reporting and learning system for general practice

  1. B Hoffmann,
  2. M Beyer,
  3. J Rohe,
  4. J Gensichen,
  5. F M Gerlach
  1. Institute for General Practice, Johann Wolfgang Goethe-University Frankfurt, Germany
  1. Dr B Hoffmann, Institute for General Practice, Johann Wolfgang Goethe-University Frankfurt, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany; hoffmann{at}allgemeinmedizin.uni-frankfurt.de
  • Accepted 18 November 2007

Abstract

Background: Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries.

Methods: Jeder Fehler Zaehlt (JFZ; www.jeder-fehler-zaehlt.de) is a web-based reporting system that receives incident reports from anonymous German-speaking users. Reports are fed into a database, classified and analysed by a team of experts. Exemplary reports are published on the internet and in journals, and the reporting system provides the opportunity for users to comment on and learn from these incidents.

Results: The incident reporting system received 199 reports in the 17 months following its launch, of which 188 were classifiable. Of these, 72.9% were classified as process errors and 26.1% as knowledge/skills errors. The most frequently reported process errors were treatment errors (32.2%), communication errors (12.6%) and investigation errors (8.5%). Of the classified errors, 41.5% were associated with harm to the patient. More than 300 comments were made, mostly by anonymous users of the system.

Conclusions: JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.

Footnotes

  • Funding: The development of the system was self-funded. Since October 2005 a grant provided by the Federal Ministry of Health (project number 212A-43794-1/117) has enabled further work on the system.

  • Competing interests: None.

  • Ethics approval: The reporting system was approved by the ethics committee of the medical faculty of the Christian-Albrecht-University Kiel, where the project was originally conceived, and by the Independent State Centre for Data Protection Schleswig-Holstein.