Focus Groups Explore Errors, Solutions in Diagnostic Testing Process

Studies estimate that 15 percent to 54 percent of reported medical errors in family medicine relate to the diagnostic testing process, say the authors of a new study. They define the diagnostic testing process, which doesn't include the tests themselves, as a continuum that ranges from ordering a test to taking follow-up action with a patient.

"The Testing Process in Family Medicine: Problems, Solutions and Barriers as Seen by Physicians and Their Staff: A Study of the American Academy of Family Physicians' National Research Network" was published in the March issue of the Journal of Patient Safety. The abstract for the report recently was posted online.

The report uses information collected from participants in a project that described testing process errors. About six months after family medicine offices in the original testing-process study began reporting errors, 139 physicians and staff members at eight participating offices (four private practices and four residency clinics) formed focus groups to address questions such as

The study focuses on information provided by these focus groups. Principal investigator Nancy Elder, M.D., M.S.P.H., associate professor in the family medicine department at the University of Cincinnati, and her colleagues analyzed focus group comments and identified several categories of errors: charting and filing (throughout the testing process), ordering and implementation of the test, tracking and return of information to the physician, the physician's response and documentation, notification of the patient, and follow-up with the patient.

The focus groups discussed contributing factors, such as a failure to follow procedures, that allowed the errors to happen. Changes the focus groups suggested to improve the testing process fell into five categories: technology, staffing, systems, communication and knowledge.

The focus groups also identified barriers to changing the testing process in two categories: culture and process. Culture-related barriers included "problems with leadership and staff involvement and support, the perceived tension for change, and understanding patient needs," say the authors. Process barriers included costs, sources of ideas, external supports, the work environment, feedback and staffing changes.

Under the heading of "monitoring and feedback," one focus group member said, "We don't have a way of tracking what types of errors that people are picking up on. … So we don't have a way of saying, 'OK, it's obvious that we've got a problem in this area and let's focus on it.'"

"We believe the most significant findings are how the perceived barriers, the contributing factors and the desired improvements relate to each other," the authors say.

"The most commonly reported contributing factors (not following procedures, lack of standardization and inadequate systems) were seen again in the cultural barriers noted by our participants (personal resistance to change, lack of buy-in from staff or providers, no perceived consequences)," say the authors. "A physician who insists on 'doing things his own way' and does not follow existing procedures also exhibits no support for proposed office-wide changes. These cultural barriers are much harder to overcome than process barriers when effecting organizational change."

The most frequently mentioned desired improvements (technology and more staff) were not related to the most frequently mentioned contributing factors or perceived barriers, the authors discovered. "Trying to improve by doing more of the same is consistent with existing literature in which most physicians suggest preventing errors by being more diligent within the same system," the authors note.

They also say that "Evidence exists that some EHRs (electronic health records) may improve quality and decrease errors, especially when they include a digital interface to the laboratory and results management software, but technology can also introduce other errors."

Future research must test ways to solve problems in the testing process while taking barriers into account, the authors conclude.

The study was funded by the Agency for Healthcare Research and Quality, and each of the eight participating offices had at least one participant who belonged to the AAFP's National Research Network.