 Medical error reporting systems must be voluntary and confidential, says James Martin, M.D. |
BY J.M.BRODIE
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AAFP leaders and staff made the case for confidential, voluntary medical error reporting systems in primary care March 13 on Capitol Hill.
In presentations before congressional aides and the media, the AAFP representatives reinforced action the House took March 12. It passed H.R. 663, the Patient Safety and Quality Improvement Act, by a 418-6 vote.
"The bill would continue the patient safety work of the Agency for Healthcare Research and Quality," said AAFP President-elect Michael Fleming, M.D., of Shreveport, La. "It would allow patient safety reports to be gathered from physicians instead of limiting reports to hospitals and facilities."
Fleming shared this story as a case in point: "Last week, a patient came in for a urinary tract infection. I asked her what medicines she was taking, and she didn't tell me she had seen a rheumatologist who put her on methotrexate. I prescribed a sulfa drug. There was obviously potential for great harm. Thank goodness the pharmacist called me."
AAFP President James Martin, M.D., of San Antonio mentioned the misfiling of a lab report showing a patient had uterine cancer. It took a week for that mistake to be identified. Martin explained how a medical error reporting system could help track and reduce errors in primary care.
 H.R. 663 would allow patient safety reports to be gathered from physicians, says Michael Fleming, M.D. |
"The question we have is: How often does this happen in America? We know a lot about patient harm and liability, and we are starting to learn a lot about what happens inside the hospital," Martin said. "But the majority of health care in this country takes place in an outpatient setting."
He said AAFP's goal regarding patient safety is threefold: to help create a system for error reporting, to ensure that system is voluntary and confidential, and to identify ways to correct errors.
Staff members from the Robert Graham Center in Washington shared results of studies on medical errors in primary care in the United States and five other industrialized countries. Two-thirds of the treatment or diagnostic errors actually started as communication glitches -- a cascade of errors starting with information that was not communicated effectively, leading to treatment or diagnostic mistakes.
During one of the Capitol Hill presentations, AHRQ senior advisor Larry Patton lauded the idea of an error reporting system. "An analysis of near misses is critical," he said. "There will be a spectacular increase in errors reported at first. That would be a major success. What the Academy and AHRQ are trying to do is drive those things out from underground."
Patient safety resources
This list of resources includes articles and studies on medical errors, as well as pending legislation on patient safety.
"Enhancing Patient Safety One Change at a Time," FP Report, September 2002 -- http://www.aafp.org/fpr/20020900/13.html
"From Lab Reports to Wrong Vaccinations, Most Medical Errors Count as 'Process' Mistakes," FP Report, September 2002 -- http://www.aafp.org/fpr/20020900/16.html
To Err Is Human: Building a Safer Health System, Institute of Medicine, 1999 -- http://www.nap.edu/catalog/9728.html
Crossing the Quality Chasm: A New Health System for the 21st Century, Institute of Medicine, 2001 -- http://www.nap.edu/books/0309072808/html/
"Prescription Writing to Maximize Patient Safety," July/August 2002 Family Practice Management -- http://www.aafp.org/fpm/20020700/27pres.html
Family Practice Management, July/August 2002 (entire issue focuses on preventing errors in family practice) -- http://www.aafp.org/fpm/20020700/
"Medical Errors: 20 Tips to Help Prevent Them" -- http://familydoctor.org/handouts/736.html
"A Preliminary Taxonomy of Medical Errors in Family Practice" -- http://www.graham-center.org/x352.xml
"An International Taxonomy for Errors in General Practice: A Pilot Study," July 15, 2002, Medical Journal of Australia -- http://www.mja.com.au/public/issues/177_02_150702/mak10269_fm.html
"Family Physicians' Solutions to Common Medical Errors" -- http://www.graham-center.org/x396.xml
"Consequences of Medical Errors Observed by Family Physicians" -- http://www.graham-center.org/x395.xml
"Types of Medical Errors Commonly Reported by Family Physicians" -- http://www.graham-center.org/x394.xml
"The Patient Safety Grid: Toxic Cascades in Health Care Settings" -- http://www.graham-center.org/x162.xml
"Toxic Cascades: A Comprehensive Way to Think About Medical Errors" -- http://www.graham-center.org/x161.xml
H.R. 663, the Patient Safety and Quality Improvement Act -- http://www.theorator.com/bills108/hr663.html
To reach writer J.M. Brodie, e-mail mbrodie@aafp.org.
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