September 2002 • Volume 8 • Number 9 |
For AAFP's first patient safety study in 2000, 42 family physicians in AAFP's national research network agreed to record 10 errors they observed in their practices during a three-month period. What they gave was information on practice mistakes. But what they got in return was invaluable: the knowledge of where change was needed.
"I remember being horrified that I had the 10 errors within about two days' time," recalls Diane Madlon-Kay, M.D., of Minneapolis. "Almost all the mistakes had to do with lab errors -- reports came back to me quite late, and some lab results were abnormal."
The study asked FPs to report errors that made them think, "That should not happen in my practice," even if the patients were not harmed by the errors. No patients were injured by the mistakes Madlon-Kay reported. But patients could have been harmed from the delays. "I knew the late reports were something I had to do something about. Sometimes the reports were coming to me a month late," she says.
Now the lab makes it a priority to get reports back to physicians soon, says Madlon-Kay. If reports stack up, staff are pulled from other projects to handle the work or overtime is paid. Also, lab analyses are recorded on the computer. "Safety will increase as we rely less on pieces of paper," says Madlon-Kay.
Another family physician in the U.S. study agrees. "I tend to print out most of my prescriptions now, and they're readable!" says Wayne Reynolds, D.O., of Gloucester Point, Va. The shift toward electronic medical records was already under way in his practice when he participated in the patient safety study.
"The EMR lets us easily track the use of substances people might be taking advantage of, such as sleeping aids -- controlled drugs," adds Reynolds. "The electronic record allows us to track refills. Also, at each patient visit, I can call up the patient's medicine on the screen and ask, 'Do you need a refill?' The system reinforces compliance."
Not that the EMR system is foolproof. "I also keep a paper copy of each patient record," says Reynolds. "The EMR system occasionally goes down, and some correspondence still comes to us from labs or other facilities that are not yet linked to us electronically."
Since 2000, besides implementing an EMR system and checking medications at every patient visit, Reynolds' practice has taken two other steps on behalf of patient safety: watching X-ray and lab reports more closely and tracking phone messages carefully.
A third FP who participated in the 2000 study, Kim Krohn, M.D., of Minot, N.D., says she is more aware of errors and other patient safety issues as a result of participating in the study. "I am also more aware that patient safety is not an interest of many people," she says. "They prefer the bury-the-head-in-the-sand approach."
| Consider joining AAFP's national research network and participating in future projects of the new AAFP Center for Evaluation and Research in Patient Safety in Primary Care. To learn about the network and the center, contact Debbie Graham, M.S.P.H., at dgraham@aafp.org or (800) 274-2237, Ext. 3176. |
Krohn noticed that the 300-resident nursing home in Minot had changed its medication lists in such a way that the lists were, she says, impossible to interpret. When physicians made rounds, they checked the lists and made mistakes changing dosages -- simply because the lists were hard to understand.
Krohn wrote the director of nursing about the problem, sent a copy to the administrator and medical director, and got the format of the lists changed.
"Had I not been interested in patient safety as a system problem, I would have accepted the situation and tried to deal with it," says Krohn.
"At least 30 physicians have patients in this nursing home, and I was the only one who pressed the administration to make the change," she says. "Physicians get frustrated because many things are out of their control. The medication lists are a good example of physicians accepting a bad situation without trying to fix it."
To help boost the patient safety quotient in your office, check out the resources listed below.
Resources
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FP Report is published by the
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Copyright © 2002 by
American Academy of Family Physicians.