FOR IMMEDIATE RELEASE
Friday, July 30, 2004
Senior Public Relations Strategist
American Academy of Family Physicians
(800) 274-2237 Ext. 5224
WASHINGTON -- A new study suggests that most medical errors in family medicine are set in motion by errors in communication. The authors assert that by examining the chain of events preceding medical errors, researchers can more accurately identify the underlying causes of medical errors and, in turn, more effectively direct efforts to prevent them.
"A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors" was published in the July/August 2004 issue of Annals of Family Medicine.
"Cascade analysis reveals the story line of errors," explained Steven H. Woolf, M.D., M.P.H., lead author and a professor with the Department of Family Practice at Virginia Commonwealth University. "Errors are difficult to measure, not only because of inadequate reporting and varied definitions, but also because most error incidents are not single acts but chains of events. Researchers and administrators who ignore this complexity may produce skewed statistics about the consequences of errors and recommend misdirected solutions."
From June to December 2001, primary care physicians used a secure Internet connection to file anonymous reports of practice errors. Only the harms and costs affecting patients were counted and classified. Three categories of harm were used: physical injuries (physical health complications from errors during the reporting period), errors that had no reported immediate effect but that heightened the patient's risk for complications after the reporting period (such as poor control of hypertension), and psychological or emotional injuries (such as frustration or anger).
"In this and other studies, we have found that physicians and other staff rarely report on the emotional, financial, and psychological harms that patients experience as a result of errors," explained Robert L. Phillips Jr., M.D., co-author of the study and assistant director of the Robert Graham Center: Policy Studies in Family Practice and Primary Care in Washington, D.C. "It isn't clear why they don't consider these other real harms that patients experience, but it does suggest that error-reporting systems need to develop ways of assessing harm in addition to the primary reporters."
The authors pointed out several research and policy implications of their findings:
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Founded in 1947, the AAFP represents 120,900 physicians and medical students nationwide. It is the only medical society devoted solely to primary care.
Approximately one in five of all office visits are made to family physicians. That is nearly 192 million office visits each year — nearly 66 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty. Family medicine’s cornerstone is an ongoing, personal patient-physician relationship focused on integrated care.
To learn more about the specialty of family medicine, the AAFP's positions on issues and clinical care, and for downloadable multi-media highlighting family medicine, visit www.aafp.org/media. For information about health care, health conditions and wellness, please visit the AAFP’s award-winning consumer website, www.FamilyDoctor.org(www.familydoctor.org).
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July 30, 2004