A preliminary taxonomy of medical errors in family practice

Dovey, Susan; Meyers, David; Phillips, Robert L.; Green, L A; Fryer, George E.; Galliher, James M.; Kappus, Jennifer; Grob, P

doi:10.1136/qhc.11.3.233

Cited by 261 publications

(250 citation statements)

References 20 publications

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“…26 Somewhat surprisingly, however, our data showed that administrative errors were frequently considered to carry with them the potential to lead to significant patient AEs, which supports our approach of encouraging all office staff to be involved in near-miss reporting. The events judged to be associated with the highest potential cost were those involving dispensing medication or implementing treatment (30% judged to involve "a lot" of potential cost) and handling test results (22% judged as "a lot").…”

Section: Discussionmentioning

confidence: 48%

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Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Crane

Sloane

Elder

et al. 2015

The Journal of the American Board of Family Medicine

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Purpose: Near-miss events represent an opportunity to identify and correct errors that jeopardize patient safety. This study was undertaken to assess the feasibility of a near-miss reporting system in primary care practices and to describe initial reports and practice responses to them.Methods: We implemented a web-based, anonymous near-miss reporting system into 7 diverse practices, collecting and categorizing all reports. At the end of the study period, we interviewed practice leaders to determine how the near-miss reports were used for quality improvement (QI) in each practice.Results: All 7 practices successfully implemented the system, reporting 632 near-miss events in 9 months and initiating 32 QI projects based on the reports. The most frequent events reported were breakdowns in office processes (47.3%); of these, filing errors were most common, with 38% of these errors judged by external coders to be high risk for an adverse event. Electronic medical records were the primary or secondary cause of the error in 7.8% and 14.4% of reported cases, respectively. The pattern of near-miss events across these diverse practices was similar.Conclusions: Anonymous near-miss reporting can be successfully implemented in primary care practices. Near-miss events occur frequently in office practice, primarily involve administrative and communication problems, and can pose a serious threat to patient safety; they can, however, be used by practice leaders to implement QI changes. (J Am Board Fam Med 2015;28:452-460.)

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Section: Discussionmentioning

confidence: 48%

“…26 For each report, the primary error was defined as "the breakdown in process, or knowledge/skill deficit that led to the reported problem." In addition, up to 4 associated or "cascade" errors and up to 4 contributing factors and possible preventive measures also were coded using the same taxonomy.…”

Section: Discussionmentioning

confidence: 99%

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Crane

Sloane

Elder

et al. 2015

The Journal of the American Board of Family Medicine

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“…5 However, serious errors leading to morbidity and mortality occur regularly in family practice. 6 Understanding the epidemiology of hospital errors proved crucial for improving safety in hospitals, 7 and there needs to be a similar focus on primary care. It is important to know to measure patient safety in primary care.…”

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confidence: 99%

A Patient Safety Toolkit for Family Practices

et al. 2018

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“…Our findings are consistent with quantitative investigations showing that 86% of errors in primary care are attributable to care delivery failures as opposed to approximately 14% attributable to PCP knowledge deficits. 39 Thus, actions to reduce omissions should involve improvements in the care delivery system. Currently, many primary care practices are adopting patientcentered medical home (PCMH) models 40 -42 , which aim to improve primary care delivery through practice transformations such as investing in improving the structural capabilities of primary care practices, delivering care in teams, and implementing health information technology.…”

Section: Discussionmentioning

confidence: 99%

Primary Care Providers’ Perspectives on Errors of Omission

et al. 2017

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Background: Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions.Methods: A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview.Results: PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices.Discussion: Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs.Conclusions: Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm. (J Am Board Fam Med 2017;30:733-742.)

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A preliminary taxonomy of medical errors in family practice

Cited by 261 publications

References 20 publications

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

A Patient Safety Toolkit for Family Practices

Primary Care Providers’ Perspectives on Errors of Omission

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