Learning from Different Lenses Reports of Medical Errors in by bdi90998

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									Learning from Different Lenses:
 Reports of Medical Errors in Primary
 Care by Clinicians, Staff and Patients

  Robert Phillips                  John Hickner
  Deborah Graham                   Susan Dovey
  Nancy Elder

        A Project of the AAFP National
              Research Network
  Presented at the: 33rd NAPCRG Annual Meeting
                    October 15-18, 2005
                                                  1
                    Quebec City, Quebec, Canada
Context
• Primary Care:
  – ~½ a billion office visits annually
  – the medical home for most Americans
  – Malpractice claims = burden of serious harms and
    death from medical errors is substantial
  – Most studies of errors reported by physicians =
    important but limited lens



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Our Questions
• Will family doctors, their staffs and patients
  submit reports about lapses in patient safety?


• How will error reports differ or agree?


• Will intensive reporting days combined with
  clinical visit data permit rate estimates?


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Setting
• 10 family physician offices:
  – 5 private practices
  – 5 residency clinics
• American Academy of Family Physician
  (AAFP) National Research Network
• mix of rural, urban, and suburban, private and
  community practices


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Asked to Report
• ―That should not have happened and that you
  don’t want to happen again‖
• Small or large, administrative or clinical
• Could be events or processes that didn’t happen
  but should have happened




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Reporting tool
• Physicians and staff were given the option of two
  methods of reporting:
  – via the Internet to the AAFP Patient Safety
    Reports secure website
  – via written reports using a standard form


• Patients could report by same options and via an
  automated telephone system.

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Reporting tool
intensive reporting period?     specific patient?
The degree of familiarity with the patient (five-point Likert scale)
The patient’s age (years for adults, months for under 2 years of age)
Patient’s gender, ethnicity, race
Complexity and chronicity of presenting health problem
What happened? (free-text)
Seriousness of event (Likert scale)
Where event happened (9 settings and free-text)
Result—actual and potential consequences (free-text)
What contributed to the event (free-text)
What could have prevented it (free-text)
Anyone was harmed?
How often events like this happen in their practice (Likert scale)
Is there anything else you would like to tell us (free-text)

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Coding and Taxonomy
• Modified version AAFP/Linnaeus taxonomy
• Expanded to consequences/harms, contributing
  factors, and potential prevention strategies
• Flexible coding protocol
   – more than one error
   – error sequences and whether cascade
• Coding team, high inter-rater reliability to third
  level of taxonomy

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Analyses
• Frequency analyses of reports
  –   Reporter-group
  –   Intensive vs. routine reporting
  –   Reporting method
  –   Consequences and severity of errors

• MANOVA to test for differences
  – between reporting-groups in proportions of the major error-
    types reported
  – each error-type as an outcome and respondent type
    (provider/staff) as a fixed factor


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Results
• 401 physicians and staff signed a consent
  form and/or participated in site training (86%
  of eligible)
• Clinic physicians, NPs/PAs, residents, and
  staff reported 726 events, 717 with errors
  –   Staff 384 (53%)
  –   physicians 278 (38%)
  –   residents 46 (6%)
  –   NPs and PAs 18 (3%)
• 935 total errors
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Results
• Most clinicians and staff reported on web
  – (546 web-based,180 mail)
• Most reports made on routine days
  – 440 (61%) routine vs. 265 (37%) intensive days
  – More clinician reports were routine than staff
    reports (67% vs 57%, p=0.039)
• Patients submitted 126 reports but only 18 errors
  – All but eight made by mail (one by phone, seven
    by web-based tool)

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Patient reports
• 6 reports of extended waiting
• 2 reports of mistaken identity
• 1 report each
  –   unnecessary blood-draw
  –   Prescriptions
  –   poor vaccination documentation
  –   unnecessary emergency room visits (unable to reach PCP)
  –   inability to get laboratory tests due to lack of insurance
  –   inappropriate comments by clinicians
  –   clinician-induced fear (patient left without treatment)
  –   credit card theft

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Clinician and Staff reports
• 1st level--96% were process errors
• Clinicians were significantly more likely to report
   – errors related to medications, laboratory
     investigations, and diagnostic imaging
• Staff were significantly more likely to report
   – communication with patients and appointments.




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Multiple errors
• Multiple errors:
   – 4 reports contained four errors
   – 33 reports contained three errors
   – 183 cases two errors
• 93 cascades
   – Chart completeness and availability; medications;
     appointments; laboratory; patient flow; and filing
     systems.

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Consequences & harms
• 706 reports had consequences or harms
  – No patient died
  – 3 patients required urgent care, were admitted to
    a hospital, or had to visit the emergency room
  – 4 patients suffered pain or injury
  – 10 patients’ health condition worsened
  – Most placed the patient at heightened risk of
    harm (49%), or made the patients, their families
    or their health clinicians upset (33%).
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Seriousness
• ―Complex‖ patients more likely very/extremely
  serious harm (31% vs. 20%, p=0.013)
• No difference routine vs. Intensive (p=0.126)
• No difference in risk for patients with chronic
  conditions (29% vs. 21%, p=0.086)
• No differences for patients familiar vs. unfamiliar




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Discussion
• Confirm that physicians and staff will report
  errors anonymously
• Considerable variation in reporting
• Routine reporting does not approximate volume
  of errors
   – Need better understanding of what to report and
     when so as not to miss common mistakes that
     result in harm uncommonly
• Reports by clinicians and staff suggest they do
  offer different lenses
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Discussion
• Chaotic busy days, healthcare team
  communication failures, and breakdowns in
  protocols or guidelines often leave patients
  vulnerable
• ―Complex‖ patients should raise concern of
  serious harms
• Reporters have difficulty divorcing systematic
  errors from blame


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Discussion
• Since multiple errors and error-cascades are
  common, take care that reporting tools can
  capture them
• Patients either don’t see errors often, won’t
  report them, or this tool did not fit their needs—
  understanding errors from their perspective will
  require another approach



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Limitations
• Reporting Variation
   – 2 practices submitted 11.2 and 7.3 reports/reporter
   – the rest submitted 0.7 to 1.3 per reporter
   – might reasonably expect one report per participant over a
     10 week period
   – Veteran’s Administration found that only 4.15% of tort
     claims had been reported in the patient incident reporting
     system and concluded, ―all reporting systems--even the
     mandatory ones--are voluntary

  Schmidek JM, Weeks WB. Relationship between tort claims and patient incident reports in the
  Veteran Health Administration. Qual Saf Health Care 2005; 14:117-122.

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Limitations
• Unable to directly contact reporters and limited
  interpretations of their reports, resulting in the
  coders introducing their own biases in data
  interpretation
   – may benefit from new Patient Safety Organization
     data that protects reports from discovery




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Limitations
• Small response sizes from residents, NPs, and
  PAs
• Generalizability




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Thanks to
• Jennifer Kappus, Aaron Bonham, Elias Brandt, and
  Miriam Dickinson
• The physicians, staff, and patients of the 10 practices
  who participated.
• Special thanks to the NRN practice Lead Physicians and
  Study Coordinators who made this study possible.
       This project was supported by grant number
5 P20 HS011584 from the Agency for Healthcare Research
                      and Quality


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