Pilot Study #1: Physician, Staff, and Patient-Reported Errors in Primary Care

Data collection was completed in June 2003.

Aims of Study

To understand if family doctors, office staff, and patients will report medical errors and lapses in patient safety during a defined, intensive study period
To compare patterns of errors reported by doctors, office staff, and patients
To estimate errors in primary care practices as reported by physicians, staff, and patients
To test and refine error-reporting tools
To explore linkage and sequence of events, when possible

Reporting Tools

Web-based reporting tool (to be used by physicians, staff, and patients)
Telephone reporting tool (to be used by patients only)
Paper reporting tool (to be used by physicians, staff, and patients)

Sample Sites

Five family physician offices and five family practice residency clinics
Each office will have physicians who are members of National Research Network
Practices will represent rural, urban, and suburban sites, as well as private and community health practices

Reporting Schema

Participants from each office will do Sentinel Error Reporting for ten weeks and Intensive Error Reporting for five days
Each practice will choose one of following schemes to report every single incident that they observe (Intensive Error Reporting):
- one of the ten weeks of the study period
- one day every other week for 10 weeks

Staff

Principal Investigator: John M. Hickner, M.D., M.S. (AAFP National Research Network)
Lead Investigator: Robert L. Phillips, M.D., M.S.P.H. (AAFP Robert Graham Center)
Co-Investigators: Susan M. Dovey, Ph.D., (AAFP Robert Graham Center), James M. Galliher, Ph.D. (AAFP National Research Network), Deborah G. Graham, M.S.P.H. (AAFP National Research Network)
Research Associate: Jennifer A. Kappus (AAFP National Research Network)
Research Assistant: Elias Brandt (AAFP National Research Network)
Consultants: Anthony J. Kuzel, M.D. (Virginia Commonwealth University), Wilson D. Pace, M.D. (University of Colorado Health Sciences Center & The Colorado Research Network)

Funding

This study is funded in part by the Agency for Healthcare Research and Quality, with additional funding provided by the American Academy of Family Physicians.

Publications

Phillips RL, Dovey SM, Graham D, Elder NC, Hickner JM. Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff and Patients. A Project of the AAFP National Research Network. In press: Journal of Patient Safety.

Phillips RL, Dovey SM, Hickner JM, Graham D, Johnson M, Robinett T. The AAFP Patient Safety Reporting System: Needed bridges for the next chasms in patient safety. Advances in Patient Safety: From Research to Implementation. Volume 3, AHRQ Publication No. 050021 (3). February 2005. Agency for Healthcare Research and Quality, Rockville, MD.

Graham DG, Pace W, Kappus J, Holcomb S, Galliher JM, Duclos CW, Bonham AJ. The challenges and successes of institutional review board review and approval of practice-based research network patient safety research studies. Advances in Patient Safety: From Research to Implementation. Volume 3, AHRQ Publication No. 050021 (3). February 2005. Agency for Healthcare Research and Quality, Rockville, MD.

Presentations

Developing a Patient Safety Taxonomy for Ambulatory Primary Care Settings -- Susan Dovey, PhD; Bob Phillips, MD, MSPH; Larry Green MD; John Hickner, MD, MS. Presented at the Ambulatory Primary Care Patient Safety Conference, September 2003, Chicago IL
(20-page PowerPoint file; About Downloading)

Developing a Patient Safety Taxonomy for Ambulatory Primary Care Settings -- Susan Dovey, PhD. Presented at the Primary Care Taxonomy Meeting, June 2004, Leawood, KS
(21-page PowerPoint file; About Downloading)

Developing a Patient Safety Taxonomy for Ambulatory Primary Care Settings -- Deborah Graham, MSPH; Bob Phillips, MD, MSPH. Presented at the Primary Care Taxonomy Meeting, October 2004, Orlando FL
(9-page PowerPoint file; About Downloading)

Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff and Patients -- Robert Phillips, MD, MSPH; John Hickner, MD, MS; Deborah Graham, MSPH; Susan Dovey, PhD; Nancy C. Elder, MD, MSPH. Presented at NAPCRG Annual Meeting, 2005
(23-page PowerPoint file; About Downloading)

Patient Safety Event Reports by Family Physicians, Staff, and Patients -- Robert Phillips, MD, MSPH; Deborah Graham, MSPH; Susan Dovey, PhD; Nancy C. Elder, MD, MSPH; Jennifer Kappus; John Hickner, MD, MS. Presented at WONCA Orlando, FL, 2004
(21-page PowerPoint file; About Downloading)

Pilot Studies

Pilot Study #1: Physician, Staff, and Patient-Reported Errors in Primary Care

Pilot Study #2: Laboratory and Imaging Process Errors in Family Physician Offices