West D, Harris D, Pace W, Main D, Fernald D; AcademyHealth. Meeting (2003 : Nashville, Tenn.).
Abstr AcademyHealth Meet. 2003; 20: abstract no. 752.
The CNA Corporation, Healthcare Policy and Operations Research Center, 9352 S. Mountain Brush St., Highlands Ranch, CO 80126 Tel. (303) 470-6356 Fax (703) 824-2256
RESEARCH OBJECTIVE: Using qualitative and quantitative approaches, analyze data on ambulatory, primary care medical errors collected via a voluntary patient safety reporting system implemented in two Colorado Practice-Based Research Networks (PBRNs), along with comparative data from malpractice insurance claims and other sources to identify patterns and explore the epidemiology of ambulatory primary care medical errors, with a focus on their potential to cascade into patient harm. Use this information to guide the development of targeted interventions at the practice level to reduce threats to patient safety. STUDY DESIGN: Event Reports were coded using comprehensive medical error taxonomy, and analyzed using a mixed methods approach incorporating quantitative analysis of coded results, as well as qualitative analysis of report narratives using commercially available qualitative analysis software. The resulting picture of errors and error-related events was used to inform the development of interventions using expert panels from participating practices to develop collaborative interventions at the practice level. Interventions underway will be evaluated using a non-equivalent control group quasi-experimental design. POPULATION STUDIED: Error reports submitted by consented clinicians and administrative staff in approximately 30 primary care practices involving nearly 600 clinicians and staff within two Colorado Practice-Based research networks. PRINCIPAL FINDINGS: To date, over 300 reports have been received and coded for analysis using the taxonomy. The most common forms of error reported involved diagnostic testing, poor communication, missing information, delays, and/or clinical procedure mistakes. Patients and settings external to the primary care practice were frequently participants in error events as contributors or mitigators. All error types carried at least some probability/risk of cascading into patient harm, but only 22% of reported events overall actually did so. Some kinds of error events (notably those involving medication, failure to disclose information to a patient, delays, lack of clinical knowledge or skill, and information transmission from a patient or another office to the primary care practice) were more likely to cascade into harm than were others. Based on frequency of occurrence and likelihood of cascading into harm, we selected diagnostic testing errors and medication/prescribing errors, respectively, for developing and testing targeted interventions CONCLUSIONS: A voluntary patient safety reporting system implemented in ambulatory primary care practices in two Colorado Practice-Based Research Networks resulted in over 300 reports of error events during its first year of operation, allowing us to analyze, learn from, and develop targeted interventions to mitigate ambulatory error events, and demonstrating the power of such reporting systems for this purpose. The epidemiology of ambulatory primary care practices emerged from our analysis, revealing a profile of error types and error processes that informed our development of targeted interventions. IMPLICATIONS FOR POLICY, DELIVERY OR PRACTICE: It is feasible to develop and implement focused patient safety interventions from the reporting and analysis of medical error data.
Publication Types:
Keywords:
- Ambulatory Care
- Colorado
- Communication
- Forms and Records Control
- Humans
- Learning
- Medical Errors
- Primary Health Care
- Thinking
- classification
- therapy
- hsrmtgs
Other ID:
UI: 102275720
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