September 2002 • Volume 8 • Number 9 |
Family doctors in six countries agree: Most medical mistakes are process errors. In the first international study of patient safety in primary care, only about one-fifth of the errors come from a lack of knowledge and skills.
And those failures, all reported by FPs and GPs, are attributable to physicians, nurses, pharmacists, receptionists -- almost anyone in health care.
"The results of the international study were very similar to those of the U.S. study done in 2000," says Susan Dovey, analyst at the Robert Graham Center in Washington. Dovey coordinated both studies.
"Some people have asked us not to focus on the 21 percent of errors related to knowledge and skill, because that might feed into the 'name/blame/shame' culture we want to get away from. That culture prevents physicians from being willing to report errors," says Dovey. "But the physicians' own reports indicate a mix of process errors and shortfalls in knowledge and skills. If we were politically correct and just concentrated on systems errors, we wouldn't be right."
Besides, she adds, the knowledge and skills mistakes have implications for education, including CME and education for administrative staff. Dovey suggests health professionals need to learn they can make changes -- things they know are wrong can be reversed. One physician in the international study commented on "overcoming learned helplessness."
See the graph below for the types and numbers of errors 80 physicians reported from the United States, Australia, Canada, England, the Netherlands and New Zealand -- developed countries with similar primary health care systems.
Some reflections from U.S. physicians in the international study:
"Big problems grow from small-acorn errors."
"Errors in communication frequently set the scene for more complex errors."
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Examples of mistakes the physicians from the six countries reported:
Flow charts for vaccinations sometimes have more spaces for vaccination dates to be recorded than the vaccination recommendations call for. In several instances, a child received an extra vaccination because of the flow chart error. "Immunization guidelines change frequently," says Dovey. "This area needs attention."
Physicians said different doctors had prescribed contraindicated drugs for a given patient. "Continuity of care is emerging as a really important issue in protecting patients from harm," says Dovey.
The physical structures of doctors' offices may threaten patient safety. Two physicians reported that patients fell and suffered injuries from the hard tile floor. "We're dealing with vulnerable patients, many of them elderly, in these environments," says Dovey, noting that a carpet might have minimized the injury.
Mistakes in diagnostic test reports were mentioned by many physicians. Sometimes lab tests that should have been done with fresh blood were done late, often after a weekend. The physicians realized the lab results were skewed, and the patients were not harmed by the faulty reports. Another problem was incorrect transcription. For instance, a pathologist might dictate the report on the biopsy of a mole as "Margins unclear." The transcriber might hear, "Margins clear." "Several physicians in the study said they rely too much on tests," says Dovey. "They recognized their instincts are also valid!"
In country after country, physicians said they needed more linguists. "People who get into medical school in most of these countries speak English," says Dovey, noting that Australia, the United States and England have many immigrants who do not speak English. There are not enough health care workers from other countries. Physicians also often commented on needing more nurses.
The physicians said they needed "more time, more staff, more computers," says Dovey.
She credits error-reporting systems with giving physicians a means of self-reflection. "Our studies offer head space for doctors to think about improving systems -- we offer thinking room," she says.
See the resources box for the citation of the international study, as well as other patient safety materials.
FP Report is published by the
AAFP News Department.
Copyright © 2002 by
American Academy of Family Physicians.
