Approaches to Error Reduction in a Teaching Family Practice

Presenter: Lawrence R. Wu, MD, Associate Clinical Professor

Insitution: Department of Community & Family Medicine, Duke University School of Medicine

Introduction: Academic family practice clinics are challenged with assuring patient safety practices in the day to day operations as well as assuring that residents and other learners develop and apply patient safety strategies after training. Family practices are responsible for assuring quality in prevention, care for acute illness, outpatient treatment as well as in-patient care. Strategies to improve and teach patient safety in such settings have not been well documented in literature.

Methods: This is a descriptive summary of the strategies and results from implementing safety improvement practices in an academic Family Practice. Duke Family Medicine sees approximately 45,000 outpatient visits a year, and is staffed by 24 Residents, and 8 full time equivalents of Faculty.

In their first year, residents are oriented to the operations of the clinic including systems to assure appointment access, timeliness of care and the concept of informed decision making with the patient. Interns are introduced to common guidelines including US Preventive Services Taskforce for prevention, JNC 7 for hypertension, pediatric immunizations and ADA guidelines for diabetes. All providers are required to incorporate these guidelines as well as drug allergies in their dictations.

Second and third year residents are required to participate in an ongoing quality improvement (QI) program which serves as non-punitive error reporting system for the clinic with peer review and systems solutions. The QI system uses the FADE (focus, analyze, develop and evaluate) technique requiring residents to gather and analyze data. Working in an interdisciplinary team to complete a consultation report, residents prescribe systems remedies to rectify errors and improve HEDIS quality measures. Systems improvements suggested from learners have included the creation of an immunization case manager, and case manager to oversee the follow up of abnormal pap smears.

By the end of residency, each resident has participated in one to three QI projects, participated in a practice QI meeting and attended a lecture on patient safety. In addition, patient safety is the core focus of 10-20% of didactic material presented on the inpatient medical service. Morbidity/mortality conferences are researched by residents that review systems changes and clinical practices that are necessarily to ensure patient safety.

In the outpatient clinic, residents learn to use guidelines to provide prevention and health promotion and are introduced to nursing roles to reduce error. An electronic medical record is used for the following functions to improve patient safety: 1) review of prevention and screening 2) review of drug allergies 3) review of chronic medical problems

Results: Over a two year period, the clinic has improved the rate of asthmatic patients on inhaled cortical steroids, percentage of diabetic patients receiving HgbA1C’s, blood pressure control and pap smear rates. A detailed curriculum and clinical outcomes data will be presented.

Discussion: Residents and other learners can be embedded in quality improvement and other systems to learn to reduce error in an outpatient practice. Traditional teaching has focused on the resident to think harder and work harder. In its 2003 report, Health Professions Education – A Bridge to Quality, the Institute of Medicine recommends that health professionals develop the following competencies during their training: provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement and utilize informatics. Present and future challenges to teaching and reducing errors include : measuring these competencies among learners and the effect on future practice, developing cost-effective computer order entry systems for outpatient prescriptions and developing regional error reporting systems in partnerships with other care takers.