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- Communication Improvement 1
- Education and Training 1
- Error Reporting and Analysis 1
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Research Directions 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Medication Safety 1
- Psychological and Social Complications 2
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Cases & Commentaries
- Web M&M
Allan Krumholz, MD; December 2004
At a new patient visit, a man with seizure disorder requests a 'handicapped' license plate due to difficulty walking long distances. To his surprise, the physician explains that he needs to report his seizures to the DMV.
Journal Article > Study
'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.
Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-736.
The systems approach to analyzing adverse events emphasizes how active errors (those made by individuals) and latent errors (underlying system flaws) contribute to preventable harm. Adverse events in ambulatory care may arise from an especially complex array of latent errors. This paper explores the role of time management problems, which the authors term "tempos," as a contributor to errors in ambulatory care. Through a review of closed malpractice claims, the authors identify 5 tempos that can affect the risk of an adverse event: disease tempo (the expected disease course), patient tempo (timing of complaints and adherence to recommendations), office tempo (including the availability of clinicians and test results), system tempo (such as access to specialists or emergency services), and access to knowledge. The role of these tempos in precipitating diagnostic errors and communication errors is discussed through analysis of the patterns of errors in malpractice claims. A preventable adverse event caused by misunderstanding of disease tempo is discussed in this AHRQ WebM&M commentary.
Rabin RC, Kaiser Health News. Washington Post. March 31, 2014.
This newspaper article reports on factors contributing to physician burnout and describes obstacles to resolving it. Burnout in the primary care setting was often related to business aspects such as insurance payments, managing staff, and increased oversight. Physician happiness was found to be tied to patient satisfaction, and electronic medical record use was perceived to impede meaningful interaction.
Advocate Redi-Code+ blood glucose test strips by Diabetic Supply of Suncoast: recall—labeling error.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; June 11, 2014.
This announcement describes a recall of blood glucose test strips due to missing information on the label that could result in accidental misuse of test strips and potential delays in diagnosis and treatment of hyper- or hypoglycemia.
Journal Article > Commentary
Rubin R. JAMA. 2019;321:2059-2062.
Patients with chronic pain can experience unintended consequences related to prescription limitation policies implemented to address the opioid epidemic. This commentary offers insights from primary care providers and regulators regarding the difficulty of managing opioid prescriptions to limit misuse while effectively treating pain.