PROFESSIONAL ISSUES

FP study highlights ripple effect: Harm flows from simple errors

The next step will be proposing solutions for error reduction in the family physician's office.

By Andis Robeznieks, AMNews staff. Sept. 23/30, 2002. Additional information

Much attention has been paid to hospital-based medical errors, but a recent study of the practice setting found that even the most minute mistakes made there can also have far-reaching consequences.

"Common and apparently trivial health system problems in primary care can sometimes harm and even kill patients," said the authors of "A preliminary taxonomy of medical errors in family practice." The study, published in the September Quality and Safety in Health Care, looks at preventing errors in the primary care setting. Previous research has focused mostly on hospital settings.

Noting that Americans visit doctors' offices 820 million times a year compared with the 38 million times they are hospitalized, Richard Roberts, MD, board chair of the American Academy of Family Physicians, said the study was overdue.

"As Americans, we have too often misled ourselves by focusing on the dramatic -- what they call the 'rescue mentality,' " he said. "This study begins to focus us on the beginning of the health care experience: the doctor's office.

"So now, people are going to say, 'What are we going to do about it?' Well, that's a good question," he added. "One of the problems is we don't know what we don't know. We have a lot of work to do."

Susan M. Dovey, PhD, an analyst at the Robert Graham Center in Washington, D.C., who led the study, agreed that too much research had focused on hospitals. But she predicted that this would change.

"All over the world, in the developed countries, people use the terms 'health care' and 'hospital care' interchangeably," said Dr. Dovey, a native of New Zealand. "I think the 21st century will show something different, especially as more and more health care will be provided outside of hospital settings."

The study categorized 344 errors reported by 42 primary care physicians between May 9 and Sept. 26, 2000. For this study, "error" was defined as something that should not have happened, was not anticipated and made physicians say, "That should not happen in my practice, and I don't want it to happen again."

"What is most helpful about this study is that it lets them know that there are important medical errors happening in their setting," Dr. Dovey said. "Previously, they could walk away from programs on wrong-site surgery saying, 'I don't do surgery.' But this lets them know there are errors in how you process information, and it can hurt people.

"They'd say, 'This happens all the time, I can't do anything about it,' " she added. "This helps them realize there are things they don't have to live with and they shouldn't live with because they hurt patients."

Of the 344 errors, 284 (82.6%) were considered system malfunctions such as administrative mistakes, investigation failures, communication lapses and payment problems; 46 (13.4%) were considered errors made due to gaps in knowledge or skills, such as wrong or missed diagnosis, and wrong treatment decisions arising from a lack of knowledge or skills; and 14 reports (4.1%) were reclassified as "adverse events" instead of errors.

Dr. Dovey said many errors appear trivial on the surface, but some had serious consequences. For example, one death was linked to a mishandled message and, in another instance, a patient's biopsy came back positive for melanoma, but the report didn't contain any contact information.

"We don't want to lock too much into those, but there were a lot of problems with how messages were handled," she said. "Sometimes messages were attached to lab results and fell off and were not getting where they were needed."

EMRs not necessarily the answer

Some are likely to argue that the study indicates the need for electronic medical record-keeping, but Dr. Dovey said technology is not always the answer to every problem she and her colleagues uncovered.

"I certainly think EMR would be most helpful -- and is probably inevitable," she said. "But further research shows that electronic medical record-keeping won't make problems go away."

In fact, she said EMR systems bring with them "a whole new slate of errors," such as typing lab results in the wrong patient's file.

But Dr. Dovey said misdirected lab paperwork is a source of many errors and that systems are needed to lessen the occurrences. "They relate to getting the right result on the test you ordered at the time you can use it to determine the right thing to do for the patient," she said. "A big problem is you get the right test done, get the right results, but the paper is flying around and getting in the wrong place."

One problem with potentially serious consequences that the study uncovered was with "triaging" patients who needed acute care, Dr. Dovey said. For example, there were times when a physician's administrative staff failed to make timely appointments for seriously ill children.

"Very often the receptionist or administrative staff who receive phone calls initially -- if there are no clinical staff available -- [are] called upon to make clinical decisions they're not trained to make," Dr. Dovey said.

Still more to learn

Now that this research has been done, she said, the next step is to do more research.

"There is lots to learn, and we're still at the stage where we're trying to find out what's going on," Dr. Dovey said. "This was the first step: Identifying problems. The next step will be proposing solutions and seeing whether they work."

She said another report, based on studies that essentially took the Robert Graham Center study and replicated it in physician practices in six other countries, will be published soon. A preliminary report, which analyzed the findings found in Australia, was published in the July 15 Medical Journal of Australia.

Another study, funded by the Agency for Healthcare Research and Quality and about to start, will look at errors that occur during one week in a doctor's office from "three different lenses" -- the viewpoints of doctors, staff and patients.

Dr. Dovey said the Robert Graham Center was also seeking AHRQ funds for a study analyzing lab errors.

And lastly, she said the center was gearing up to do an analysis of malpractice data in an attempt to identify errors and learn how they occurred.

Dr. Roberts, who is on the board of the National Patient Safety Foundation, is heartened by the amount of research being done. But in addition to looking within, he suggested that health care borrow the error-reduction methods of other industries.

"Industrial engineers show that the more people you have involved in the process, the more errors you have," Dr. Roberts said. "For every doubling of people you have involved, you have a quadrupling of errors. That's a powerful argument for the family doc -- instead of having a specialist for every body part."

For true improvements to be made, he added, Americans need to change their health care philosophy. He said everyone seems to want either the best of the best or something quick and cheap, when the best care falls somewhere in between.

"Americans want to eat either at five-star restaurants or drive-up windows, but you can't survive on that; you need some good home cooking and vegetables," Dr. Roberts said. "In the American health care stew, I'm the vegetables, the basic ingredients."

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Adhering to a few basic principles can help prevent errors in the primary care practice.

• Insist that the primary doctor see and initial any report from another physician before it is filed.
• Tell patients: "We will contact you with test results. If you do not hear from us within X time, call us."
• Create a culture of safety where responsibilities are clear, redundancies are built in and errors are not seen as individual failings but as system challenges.
• Emphasize compassion, competence, communication and charting.

Source: Richard Roberts, MD, board chair, American Academy of Family Physicians

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AAFP news release on error study

Abstract, "A preliminary taxonomy of medical errors in family practice," Quality and Safety in Health Care, September (http://qhc.bmjjournals.com/cgi/content/abstract/11/3/233)

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Copyright 2002 American Medical Association. All rights reserved.