Patient Safety - General Errors

• Study Description and Methods
• Specific Aims and Objectives
• Timeline
• Status
• Key Findings and Publications
• Contact Information

Physician, Staff, and Patient-Reported Errors in Primary Care.

Study Description and Methods

This is a descriptive study that took place from April to June 2003 in five family physician offices and five family practice residency clinics. A lead physician and study coordinator in each of the 10 practices were included on the study team and led the study in their practices. Physicians, staff and patients submitted anonymous reports on things that happened in the practice “that should not have happened and that you don’t want to happen again.” Physicians and staff were given the option of two methods of reporting: via the Internet to the AAFP Patient Safety Reports secure website or via written reports. Patients reported by these same options and also via an automated telephone system.

Specific Aims and Objectives

1. To understand if family doctors, their office staff, and their patients will report medical errors and lapses in patient safety during a defined, intensive study period;
2. To compare patterns of errors reported by doctors, nurse practitioners/physician assistants, other staff, and patients;
   
3. To estimate error rates in primary care practices as reported by physicians, nurse practitioners/physician assistants, other staff, and patients during an intensive monitoring period;
   
4. To test and refine error-reporting tools for primary care practices; and
   
5. To explore linkage and sequence of events, when possible.
   

Timeline

This study was funded from October 1, 2001 to September 30, 2005.

Status

This study has completed data collection and is currently closed. Please see a list of publications below.

Key Findings and Publications

Mitigation of Patient Harm in Family Medicine Offices: A report from the American Academy of Family Physicians National Research Network. Graham D, Harris D, Elder NC, Emsermann C, Brandt E, Staton E, Hickner J. Quality and Safety in Healthcare 2008 17:201-208.

Medication Errors Reported by U.S. Family Physicians and Their Office Staff. Kuo, GM, Phillips RL, Graham D, Hickner JM. Quality and Safety in Healthcare 2008 17:286-90.

Barriers and motivators for making error reports from family medicine offices: A report from the American Academy of Family Physicians National Research Network. Elder NC, Graham D, Brandt E, Hickner J. J AM Board Fam Med. March-April 2007;20(2):115-23.

Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff and Patients. A Project of the AAFP National Research Network.  Phillips RL, Dovey SM, Graham D, Elder NC, Hickner JS.  Journal of Patient Safety (2006) 2 (3):140-146.

Developing and using taxonomies of errors. Dovey SM, Hickner JM, Phillips R. In: Walshe K, Boaden R. Patient Safety: Research into Practice. November 2005. ISBN: 0335218539. Open University Press, Berkshire, England. (First prize winner in the Basis of Medicine category at the 2006 British Medical Association Book of the Year competition)

The challenges and successes of institutional review board review and approval of practice-based research network patient safety research studies. Graham DG, Pace WD, Kappus JA, Holcomb S, Galliher JM, Duclos CW, Bonham AJ. In: Henriksen K, Battles JB, Marks E, Lewin DI, eds. 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. http://www.ahrq.gov/qual/advances/

The AAFP Patient Safety Reporting System: Needed bridges for the next chasms in patient safety. Phillips RL, Dovey SM, Hickner JM, Graham DG, Johnson M, Robinett TA. In: Henriksen K, Battles JB, Marks E, Lewin DI, eds 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. http://www.ahrq.gov/qual/advances/ PMID: 21249975

Can a national primary-care error reporting system make a difference in medical practice? Elder NC, Graham D, Hickner J. Focus on Patient Safety (2004) 7(1):5-6.

A preliminary taxonomy of medical errors in family practice. Dovey SM, Meyers DS, Phillips RL Jr, Green LA, Fryer GE, Galliher JM, Kappus J, Grob P. Qual Saf Health Care (2002) Sep;11(3):233-238.

Contact Information

For additional information about this study, please contact:

AAFP National Research Network
1-800-274-2237 x3180
nrn@aafp.org

This study is funded by grants from the Agency for Healthcare Research and Quality (AHRQ)