Use of colon cancer testing in rural Colorado primary care practices.

BACKGROUND: People living in rural areas may be less likely to be up to date (UTD) with screening guidelines for colorectal cancer (CRC). OBJECTIVES: To determine (1) rates of being UTD with screening or ever having had a test for CRC and (2) correlates for testing among patients living in a rural area who visit a provider. DESIGN: Cross-sectional survey. PARTICIPANTS: Five hundred seventy patients aged 50 years and older who visited their health-care provider in High Plains Research Network (HPRN) practices. MEASUREMENTS: (1) Ever having had a CRC screening test, (2) being UTD with CRC screening, and (3) intention to get tested. RESULTS: The survey completion rate was 65%; 71% of patients had ever had any CRC screening test, while 52% of patients were UTD. Correlates of intending to get tested included having a family history of CRC, having a doctor recommend a test, knowing somebody who got tested, and believing that testing for CRC gives one a feeling of being in control of their health. Of those who had never had a CRC screening test, 12% planned on getting tested in the future, while 55% of those who were already up to date intended to be tested again (p < 0.001). CONCLUSIONS: Prevalence of being UTD with CRC testing in the HPRN was on par with statewide CRC testing rates, but over three quarters of patients who had not yet been screened had no intention of getting tested for CRC, despite having a medical home.

Missing clinical information during primary care visits.

CONTEXT: The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. OBJECTIVE: To describe primary care clinicians' reports of missing clinical information. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. MAIN OUTCOME MEASURES: Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. RESULTS: Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). CONCLUSIONS: Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.

Stopping the error cascade: a report on ameliorators from the ASIPS collaborative.

OBJECTIVE: To present a novel examination of how error cascades are stopped (ameliorated) before they affect patients. DESIGN: Qualitative analysis of reported errors in primary care. SETTING: Over a three-year period, clinicians and staff in two practice-based research networks voluntarily reported medical errors to a primary care patient safety reporting system, Applied Strategies for Improving Patient Safety (ASIPS). The authors found a number of reports where the error was corrected before it had an adverse impact on the patient. RESULTS: Of 754 codeable reported events, 60 were classified as ameliorated events. In these events, a participant stopped the progression of the event before it reached or affected the patient. Ameliorators included doctors, nurses, pharmacists, diagnostic laboratories and office staff. Additionally, patients or family members may be ameliorators by recognising the error and taking action. Ameliorating an event after an initial error requires an opportunity to catch the error by systems, chance or attentiveness. Correcting the error before it affects the patient requires action either directed by protocols and systems or by vigilance, power to change course and perseverance on the part of the ameliorator. CONCLUSION: Despite numerous individual and systematic methods to prevent errors, a system to prevent all potential errors is not feasible. However, a more pervasive culture of safety that builds on simple acts in addition to more costly and complex electronic systems may improve patient outcomes. Medical staff and patients who are encouraged to be vigilant, ask questions and seek solutions may correct otherwise inevitable wrongs.

Rural community members' perceptions of harm from medical mistakes: a High Plains Research Network (HPRN) Study.

OBJECTIVE: The aim of this study was to learn about community members' definitions and types of harm from medical mistakes. METHODS: Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community newspapers. Survey included open-ended questions on patients' experiences with medical mistakes and resultant harm. Qualitative analysis was performed by CAC and research team members on mistake descriptions and types of reported harm. Patient Safety Taxonomy coding was performed on a subset of surveys that contained actual medical errors. RESULTS: A total of 286 surveys were returned, with 172 respondents (60%) reporting a total of 180 perceived medical mistakes. Quantitative analysis showed that 41% of perceived mistakes (n = 73) involved only unanticipated outcomes. Reported types of harm included emotional, financial, and physical harm. Reports suggest that perceived clinician indifference to unanticipated outcomes may lead to patients' loss of trust and belief that the unexpected outcome was a result of an error. DISCUSSION: CBPR methodology is an important strategy to design and implement a community-based survey. Community members reported experiencing medical mistakes, most with harmful outcomes. The response they received by the medical community may have influenced their perception of mistake and harm.

Pharmacy clarification of prescriptions ordered in primary care: a report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative.

INTRODUCTION: Prescription errors threaten patient safety and pharmacists often contact providers for prescription clarification. This study describes the principal reasons pharmacies call primary care practices to clarify prescriptions and subsequent implications for quality and patient safety improvement. METHODS: A cross-sectional study of 22 primary care practices participating in a patient safety study was performed. Callbacks from pharmacies were logged for 2 weeks to determine reasons for callbacks, most frequently involved drug classes, whether issues were resolved on the same day of the call, and variability of callbacks among practice types. Analyses were performed using frequencies, t tests, and chi(2) tests. RESULTS: Practices recorded 567 clarification calls, most frequently for prior authorization issues (n = 209; 37%), formulary issues (n = 148; 26%), and unclear/missing prescription dosages (n = 117; 21%). Drug classes most frequently requiring clarifications were gastrointestinal (n = 122; 21.7%), cardiovascular (n = 278; 13.9%), and analgesic/anesthetic (n = 74; 13.2%) agents. Issues were resolved on the same day 62% of the time. Residency practices averaged more issues per call (P < .001). CONCLUSIONS: Clarification calls made to primary care practices involve administrative and clinical issues, potentially impacting patient safety. Pharmacy callback data can identify potential prescription concerns, thereby helping practices develop interventions aimed at reducing errors and improving patient safety.

Exploring patient reactions to pen-tablet computers: a report from CaReNet.

PURPOSE: We wanted to study patient receptivity to using pen-tablet computers for collecting data in a practice-based research network. METHODS: We analyzed exit interviews and field notes collected by trained research assistants as part of a larger Colorado Research Network (CaReNet) study comparing pen-tablet and paper-pencil methods to collect data for the Primary Care Network Survey (PRINS). RESULTS: A total of 168 patients completed a patient exit interview after completion of the pen-tablet-based survey instrument. Analyses of these brief interviews and field notes indicated that patients had favorable reactions to using pen-tablet computers. The most common barriers were related to glitches in the technology; the voice recognition software was the most problematic, with patients (as well as clinicians) finding this feature to be frustrating. CONCLUSIONS: Patients were able and willing to use pen-tablet computers for completing forms within busy primary care offices. Increasing patient involvement in practice-based research may be even more practicable through the use of this novel technology, which can allow patient-directed data collection at a single point in time as well as longitudinally.