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Approach to Improving Safety
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Search results for "Active Errors"

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Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Patient safety incidents involving sick children in primary care in England and Wales: a mixed methods analysis.

Rees P, Edwards A, Powell C, et al. PLoS Med. 2017;14:e1002217.

Since the inception of the patient safety movement, most research has focused on the inpatient setting. Although the focus on ambulatory safety has grown in recent years, little is known about adverse events in outpatient pediatric care. In this mixed methods study, researchers analyzed incident reports involving sick pediatric primary care patients from the England and Wales' National Reporting and Learning System over a 9-year period. Using descriptive and thematic analysis, researchers sought to identify the most common and serious event types, reasons these events occurred, and opportunities for improving safety. They found that about one third of 2191 safety incidents represented cases of severe harm. Based on their analysis, the authors conclude that efforts should focus on building safer systems for medication dispensing in community pharmacies, enhancing the triage process for sick children, and improving communication between providers and parents. An accompanying editorial discusses the value of incident reports with regard to improving care for pediatric primary care patients.

Journal Article > Study

Delayed workup of rectal bleeding in adult primary care: examining process-of-care failures.

  • Classic

Weingart SN, Stoffel EM, Chung DC, et al. Jt Comm J Qual Patient Saf. 2017;43:32-40.

Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal bleeding is an important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can lead to worse outcomes. For this retrospective study, physician reviewers examined 438 abstracted medical records of patients with rectal bleeding to identify problems in the diagnostic process. In the majority of cases, they identified problems such as failure to elicit sufficient family history, incomplete physical examination performance or documentation, and lack of needed laboratory testing. Consistent with prior studies, failure to order laboratory testing and plan follow-up were associated with worse care quality. These findings emphasize the challenges of achieving timely and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing electronic health record capability and trigger tools could address diagnostic delays in primary care.

Journal Article > Commentary

Preventing diagnostic errors in primary care.

Ely JW, Graber ML. Am Fam Physician. 2016;94:426-432.

The Improving Diagnosis in Health Care report advocated for enhancing patient engagement as a strategy to reduce diagnostic error. This commentary suggests that discussing uncertainty, seeking second opinions, and utilizing a checklist to guide decision-making can help engage primary care patients in the diagnostic process.

Journal Article > Study

Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.

Tudor Car L, Papachristou N, Bull A, et al. BMC Fam Pract. 2016;17:131.

Compared with other patient safety issues, diagnostic errors have received little attention until recently. Missed or delayed diagnoses are a common reason for malpractice claims. This study sought to determine barriers and solutions to delays in diagnosis in primary care. Investigators sent a questionnaire to more than 500 clinicians and received 113 responses. Participants identified 33 discrete problems associated with delays in diagnosis and suggested 27 solutions. The main issues included inability to meet patients' care needs and inadequate communication between secondary and primary care. The top solutions included improving training of primary care doctors and enhancing communication among providers as well as between providers and patients, especially around test results. An Annual Perspective discussed diagnostic errors in more detail.

Journal Article > Study

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

Barry E, O'Brien K, Moriarty F, et al; PIPc Project Steering group. BMJ Open. 2016;6:e012079.

Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Cases & Commentaries

New Patient Mistakenly Checked in as Another

  • Web M&M

Robert A. Green, MD, MPH, and Jason Adelman, MD, MS; January 2016

Presenting to his new primary physician's office for his first visit, a man was checked in under the record of an existing patient with the exact same name and age. The mistake wasn't noticed until the established patient received the new patient's test results by email.

Newspaper/Magazine Article

Why it's so easy for doctors to misdiagnose kids.

Epstein H. The Atlantic. November 17, 2015.

Recent emphasis on diagnostic error has raised awareness of the problem. This magazine article discusses how the wide range of diseases to be considered by pediatricians and challenges associated with children's ability to recognize and describe their symptoms contribute to diagnostic complexity in this specialty.

Tools/Toolkit > Multi-use Website

Patient Safety Toolkit for General Practice.

London, UK: Royal College of General Practitioners; 2015.

Although most patient safety efforts have focused on inpatient care, the majority of health care actually takes place in the ambulatory setting. This toolkit for general practitioners in the United Kingdom provides various instruments to help prevent and analyze safety problems. Materials include a trigger tool, medication reconciliation form, and significant event audit template.

Newspaper/Magazine Article

A medical detective story: why doctors make diagnostic errors.

Landro L. Wall Street Journal. September 26, 2015.

In light of the recent IOM report on improving diagnosis, this newspaper article features an interview with Hardeep Singh, a nationally recognized expert in diagnostic errors. The interview explores his work to measure diagnostic errors, understand factors that contribute to them, and how technology and education can enhance diagnostic reasoning.

Cases & Commentaries

Dual Therapy Debacle

  • Web M&M

Steven R. Kayser, PharmD; September 2015

Following a myocardial infarction, an elderly man underwent percutaneous coronary intervention and had two drug-eluting stents placed. He was given triple anticoagulation therapy for 6 months, with a plan to continue dual anticoagulation therapy for another 6 months. Although the primary care provider saw the patient periodically over the next few years, the medications were not reconciled and the patient remained on the dual therapy for 3 years.

Journal Article > Study

Safety incidents in the primary care office setting.

Rees P, Edwards A, Panesar S, et al. Pediatrics. 2015;135:1027-1035.

Patient safety in outpatient settings is a growing concern. In this analysis of voluntarily reported safety events from the United Kingdom, researchers identified serious risks for children cared for in outpatient family medicine settings. Medication management, diagnostic errors, and errors in the referral process contributed significantly to patient harm, echoing prior studies about outpatient safety. The authors call for implementation of safety practices such as barcode medication administration, clinical decision support software, and electronic referral tracking, all of which remain incompletely implemented in ambulatory care. Given the known under-reporting of adverse events, this report likely underestimates the frequency of patient safety problems in this outpatient setting and emphasizes the need for active safety monitoring.

Journal Article > Commentary

Rethinking diagnostic delay in cancer: how difficult is the diagnosis?

Lyratzopoulos G, Wardle J, Rubin G. BMJ. 2014;349:g7400.

Past studies have found that delays in cancer diagnosis are common and harmful. Suggesting that such delays are not always due to error, this commentary reviews how diagnostic difficulty can lead to multiple consultations and hinder timely diagnosis of cancer in primary care.

Journal Article > Study

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients.

Hsu CC, Chou CY, Chou CL, et al. PLoS One. 2014;9:e114359.

Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.

Journal Article > Study

Time of day and the decision to prescribe antibiotics.

Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014;174:2029-2031.

Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.

Cases & Commentaries

May I Have Another?—Medication Error

  • Web M&M

Michael Wolf, PhD, MPH; June 2014

A man admitted to the hospital for his first seizure was found to have been taking up to 10 tablets of 10 mg zolpidem per night (an unsafe dose) to fall asleep and had recently run out. The instructions on the medication label had stated: "If ineffective, take another."

Journal Article > Commentary

Effective communication with primary care providers.

Smith K. Pediatr Clin North Am. 2014;61:671-679.

Highlighting how the disconnect between hospital medicine programs and primary care practices introduces challenges to ensuring continuity of care and information transfer, this commentary relates strategies for strengthening communication and partnership between hospitalists and primary care providers to augment these handoffs.

Cases & Commentaries

Discontinued Medications: Are They Really Discontinued?

  • Web M&M

Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA; May 2014

An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.

Journal Article > Study

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations.

  • Classic

Singh H, Meyer AND, Thomas EJ. BMJ Qual Saf. 2014;23:727-731.

Diagnostic errors are increasingly recognized as a major source of preventable patient harm. Researchers compiled several studies to estimate the frequency of these errors in outpatient care across the United States. Two studies used a trigger approach to review unusual patterns of return visits in primary care and one study included consecutive lung cancer cases. From these data, the authors determined that approximately 5% of adults in the US, or more than 12 million individuals, experience a diagnostic error in the outpatient setting every year. This is the first study to evaluate the frequency of ambulatory diagnostic errors, and the results underscore the importance of efforts to improve diagnosis by addressing cognitive and systems vulnerabilities. A recent AHRQ WebM&M commentary describes a delayed diagnosis in outpatient care.

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