NRN Research: Testing Process Errors Leading to Negative Consequences 'Common' in Primary Care

Testing process errors, as well as the adverse patient consequences that result, are common in primary care practices, although these errors rarely result in significant physical harm to patients. That's according to a study (Abstract available free; full study available for a fee.) conducted by the AAFP National Research Network, or NRN, that was published recently in the journal Quality and Safety in Health Care.

A second study in the same journal analyzed the same data and found that for nearly a quarter of testing process errors, activities were undertaken to prevent or minimize patient harm. This second study found that these mitigated errors resulted in less frequent and less serious harm to patients.

The data for the studies came from eight family medicine offices in the NRN, four of them private practices and four residency clinics. They represented rural, urban and suburban locations and small and large practices. The offices submitted 590 error event reports during 32 weeks in 2004, with a total of 966 testing process errors reported.

The first study found that each office reported errors across the spectrum of the testing process. The types of reported errors varied considerably from practice to practice; for example, test ordering errors constituted 28 percent of reported errors from one practice but only 4 percent from another practice. "This suggests that each practice must examine its own testing process to discover the weak links," study authors wrote.

About 13 percent of the reported errors related to test ordering; about 18 percent related to test implementation. Of those test implementation errors, the largest percentage (nearly 7 percent) had to do with not getting the test done.

Nearly 25 percent of errors related to getting test results to the ordering clinician in a timely manner. About 18 percent were general administrative errors, such as misfiling, and about 7 percent involved reporting test results to patients.

A significant portion of the reported errors led to adverse patient outcomes, the first study found. Nearly half of the errors led to increased inefficiency and inconvenience, such as lost time, delayed care or increased cost. Thirteen percent led to adverse clinical outcomes or pain and suffering, and 18 percent caused physical or emotional harm.

The most important association with error type and adverse outcomes was the race/ethnicity of the patient involved, the first study found. Errors of test implementation were nearly double for minority groups compared with non-Hispanic whites (32 percent versus 18 percent).

The study also found that minorities experienced a higher prevalence of harm and adverse consequences when errors were made -- a finding that troubled the study's lead investigator, John Hickner, M.D., professor of family medicine at the University of Chicago Pritzker School of Medicine.

"I can come up with some possible reasons why minority patients had problems getting their tests implemented," Hickner said. "Perhaps some patients didn't have the money to pay for the test, or they may not have had transportation to the testing site."

But he said he was surprised that errors caused harm or adverse consequences more often for minority patients than for non-Hispanic whites. "We're just not sure why that was the case," he said. Study authors called for further investigation with a more representative sample of practices.

Four of the eight practices in the research project had electronic health records, or EHRs, but the presence of an EHR appeared to have no effect on the type of errors reported.

"It's not fair to say (EHRs) don't make a difference," Hickner said, "just that we didn't detect a difference in our study, perhaps because of the small sample size. I personally think (EHRs) are a terrific tool that isn't refined enough yet to make a difference."

The second study, on mitigation of testing errors, found that most identified mitigators were persons inside the practice, not the patients themselves. Mitigation was more likely to occur if the error event included an ordering error or involved a patient age 65 or older. The odds of mitigation were lower for patients between ages 18 and 44, for implementation errors or for events involving more than one error.

"The finding about older patients is interesting," said Debbie Graham, lead investigator on the second study and associate research director for the NRN. "We don't know why errors regarding their tests were mitigated more often. Perhaps these patients have been with the practice longer and are more familiar to the doctor and staff, making it more likely that someone in the practice will track the testing process."

The first study, in conjunction with earlier studies, "strongly supports the need for office-by-office improvements in the overall testing process within primary care," the authors wrote. "Even the lower-bound estimates of frequency and harm provided by this report are unacceptable. Given the volume of lab and imaging studies performed or ordered through the primary-care system, the extent of harm, inconvenience and waste caused by errors is significant."

Hickner pointed out that, according to research from professional liability carriers, about 25 percent to 30 percent of settled claims against FPs are due to delays in diagnosis. "A fair number are due to failure to follow up on test results," he said. "It's a quality of care issue."

Hickner's advice to FPs and their staff members? "Take a look at your systems," he said. "There are all kinds of things you can do, from testing logs and tickler files to assigning a staff member to follow up on tests. Some practices are experimenting with sending test results directly to patients or using services that patients can dial into to get their test results."

The new standard of care is that all patients should get all test results, Hickner added. "The era of 'no news is good news' is over," he said.