The University of California is installing a pioneering Web-based medical-event reporting system to improve patient safety in the UC medical centers and quickly pinpoint opportunities for improvement in patient care.

The system will allow frontline medical workers to report on adverse and “near miss” medical events from most computers in a UC medical center. It will provide for early identification of trends and patterns of medical incidents. Once such patterns are identified, improvements can be made to improve patient safety.

The reports will be available to designated physicians, nurses, pharmacists, quality managers, risk managers, and administrators.

Although hospitals have had incident reporting systems of varying sophistication for years, the UC effort is the first of its type in the nation, linking academic medical centers on a systemwide basis through the Internet, with provision for monthly conferences to address findings.

The system will have built-in electronic safeguards to protect medical and patient confidentiality.

"UC is taking action to meet head-on the challenge of medical errors," said Dr. Lee Hilborne, director of the UCLA Center for Patient Safety and Quality. He is also director of the Strategic Alliance for Error Reduction in California Healthcare, a universitywide collaborative that started working on the project in 2001.

"We believe this new system will enable us to act more quickly to head off potential problems," Hilborne added.

In a 1999 landmark report, "To Err Is Human," the Institute of Medicine highlighted the importance of identifying and learning from errors and unsafe situations, declaring, "The event reporting system will not only allow us to learn about errors, but most importantly, we will correct unsafe situations before they ever have the opportunity to reach our patients." The Institute of Medicine is one of the four National Academies.

The system will allow hospitals to address such specific challenges as medication errors, adverse drug reactions, blood transfusion errors, patient falls, skin breakdown and narcotics discrepancies. It also includes establishment of a UC-wide severity ranking or "harm score system" under which each incident report will be valued and compared within and across each campus.

The date for completion of the system is early May.

The University of California's five medical centers comprise one of the largest health care systems in California and one of the two largest Medi-Cal providers in the state. They are operated by UC Davis, UC Irvine, UCLA, UC San Francisco and UC San Diego.

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