Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

OBJECTIVES: Little research has focused on preventing harm from errors that occur in primary care. We studied mitigation of patient harm by analysing error reports from family physicians' offices. METHODS: The data for this analysis come from reports of testing process errors identified by family physicians and their office staff in eight practices in the American Academy of Family Physicians National Research Network. We determined how often reported error events were mitigated, described factors related to mitigation and assessed the effect of mitigation on the outcome of error events. RESULTS: We identified mitigation in 123 (21%) of 597 testing process event reports. Of the identified mitigators, 79% were persons from inside the practice, and 7% were patients or patient's family. Older age was the only patient demographic attribute associated with increased likelihood of mitigation occurring (unadjusted OR 18-44 years compared with 65 years of age or older = 0.27; p = 0.007). Events that included testing implementation errors (11% of the events) had lower odds of mitigation (unadjusted OR = 0.40; p = 0.001), and events containing reporting errors (26% of the events) had higher odds of mitigation (unadjusted OR = 1.63; p = 0.021). As the number of errors reported in an event increased, the odds of that event being mitigated decreased (unadjusted OR = 0.58; p = 0.001). Multivariate logistic regression showed that an event had higher odds of being mitigated if it included an ordering error or if the patient was 65 years of age or older, and lower odds of being mitigated if the patient was between age 18 and 44, or if the event included an implementation error or involved more than one error. Mitigated events had lower odds of patient harm (unadjusted OR = 0.16; p<0.0001) and negative consequences (unadjusted OR = 0.28; p<0.0001). Mitigated events resulted in less severe and fewer detrimental outcomes compared with non-mitigated events. CONCLUSION: Nearly a quarter of testing process errors reported by family physicians and their staff had evidence of mitigation, and mitigated errors resulted in less frequent and less serious harm to patients. Vigilance throughout the testing process is likely to detect and correct errors, thereby preventing or reducing harm.

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network.

CONTEXT: Little is known about the types and outcomes of testing process errors that occur in primary care. OBJECTIVE: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff. DESIGN: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting. SETTING AND PARTICIPANTS: 243 clinicians and office staff of eight family medicine offices. MAIN OUTCOME MEASURES: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors. RESULTS: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p<0.05) existed between error types and type of reporter (clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients' race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45-64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm. CONCLUSIONS: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

BACKGROUND: It is unknown if successful changes in specific safety practices in the intensive care unit (ICU) generalize to broader concepts of patient safety by staff nurses. OBJECTIVE: To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital acquired infections. METHOD: After implementation of practices that reduced catheter-related bloodstream infections in ICUs at four community hospitals, ICU nurses participated in focus groups to discuss patient safety. Audiotapes from the focus groups were transcribed, and two independent reviewers categorised the data which were triangulated with responses from selected questions of safety climate surveys and with the safety checklists used by management leadership on walk rounds. RESULTS: Thirty-three nurses attended eight focus groups; 92 nurses and managers completed safety climate surveys, and three separate leadership checklists were reviewed. In focus groups, nurses predominantly related patient safety to dangers in the physical environment (eg, bed rails, alarms, restraints, equipment, etc.) and to medication administration. These areas also represented 47% of checklist items from leadership walk rounds. Nurses most frequently mentioned self-initiated "double checking" as their main safety task. Focus-group participants and survey responses both noted inconsistency between management's verbal and written commitment compared with their day-to-day support of patient safety issues. CONCLUSIONS: ICU nurses who participated in a project to decrease hospital acquired infections did not generalize their experience to other aspects of patient safety or relate it to management's interest in patient safety. These findings are consistent with many adult learning theories, where self-initiated tasks, combined with immediate, but temporary problem-solving, are stronger learning forces than management-led activities with delayed feedback.

Teaching medical students to give bad news: does formal instruction help?

BACKGROUND: In 1994, the Oregon Health Sciences University instituted an integrated course (Principles of Clinical Medicine; PCM) of classroom and outpatient clinic experience designed to give first- and second-year medical students a head start in clinical skills. During their third year, the students have been periodically evaluated by objective structured clinical examinations (OSCEs). Part of the OSCE assesses the student's skills in giving bad news by means of role playing. Assessment criteria fall into those measuring knowledge and those evaluating humanistic skills. METHODS: To evaluate whether formal instruction in giving bad news leads to an improvement in a medical student's skills, the bad-news portions of the OSCE scores of third-year medical students taught by the old curriculum (OC) were compared with those of third-year students who had taken PCM. RESULTS: While bad news knowledge scores did not differ significantly between the two groups of students, the average bad-news humanistic score was significantly better for the PCM group (85% vs 79%; p = 0.05). There was no significant difference in average scores for either knowledge or humanistic skills between male and female students in the PCM group. The benefit of PCM regarding delivering bad news was also reflected by a survey of attending physicians who had taught students under both the old and the new curricula. The majority of those surveyed scored students' skills in related areas better after PCM. CONCLUSION: Formal instruction in the first two years of medical school improved students' humanistic skills as they relate to the delivery of bad news.

Malpractice claims against family physicians are the best doctors sued more?

BACKGROUND: Physicians who have been sued multiple times for malpractice are assumed to be less competent than those who have never been sued. However, there is a lack of data to support this assumption. Competence includes both knowledge and performance, and there are theoretical reasons to suspect that the most knowledgeable physicians may be sued the most. METHODS: We conducted a retrospective cohort study of family physicians who were included in the Florida section of the 1996 American Medical Association's Physician Masterfile and who practiced in Florida at any time between 1971 and 1994 (N = 3686). The main outcome was the number of malpractice claims per physician adjusted for time in practice. Using regression methods, we analyzed associations between malpractice claims and measures of physician knowledge. RESULTS: Risk factors for malpractice claims included graduation from a medical school in the United States or Canada (incidence rate ratio [IRR] 1.8; 95% confidence interval [CI], 1.6-2.1), specialty board certification (IRR 1.8; 95% CI, 1.6-2.1), holding the American Medical Association Physician's Recognition Award (IRR 1.4; 95% CI, 1.2-1.7), and Alpha Omega Alpha Honor Society membership (IRR 1.8; 95% CI, 1.1-3.0). Among board-certified family physicians, sued physicians who made no payments to a plaintiff had higher certification examination scores than nonsued physicians (53.48 vs 51.38, P < .01). The scores of sued physicians who made payments were similar to those of nonsued physicians (51.05 vs 51.38, P = .93). CONCLUSIONS: Among Florida family physicians, the frequency of malpractice claims increased with evidence of greater medical knowledge.

Use of alternative health care by family practice patients.

In recent years, the use of alternative medicine has become more acknowledged in the United States. Many different practices are encompassed by the terms alternative, unorthodox, or complementary medicine, and their use by the population is just now being defined. The number of established family practice patients also using alternative medicine is not yet known. To help answer this question, a survey of family practice patients concerning their use of alternative medicine was performed in 4 family practices in a large community in the western United States. Volunteers from the survey respondents attended a focus group to discuss more fully their use of alternative medicine. Questionnaires were completed by 113 family practice patients. Fifty percent (57/113) of patients had or were using some form of alternative medicine, but only 53% (30/57) had told their family physician about this use. No significant difference in the percentage who used alternative medicine or who told their physician about it was attributable to gender, educational level, age, race, or clinic attended. The main reason given for using alternative medicine, alone or in combination with care from a family physician, was a belief that it would work. Many of those who worked in combination with a family physician spoke of acceptance and control, but those who did not work with their physician mentioned traditional medicine's limitations and narrow-mindedness. Family physicians need to be aware that many of their patients may be using alternative health care. Open and nonjudgmental questioning of patients may help increase physician knowledge of this use and lead to improved patient care as physicians and patients work together toward health.

Fictional women physicians in the nineteenth century: the struggle for self-identity.

By the late nineteenth century, there were large numbers of women physicians in the United States. Three Realist novels of the time, Dr. Breen's Practice, by William Dean Howells, Dr. Zay, by Elizabeth Stuart Phelps and A Country Doctor, by Sarah Orne Jewett, feature women doctors as protagonists. The issues in these novels mirrored current issues in medicine and society. By contrasting the lives of these fictional women doctors to their historical counterparts, it is seen that, while the novels are good attempts to be truthful treatments of women physicians' struggles, in certain areas they do not accurately address the concerns of women physicians.

Reading and evaluating qualitative research studies.

Qualitative research is now published across the family practice and medical literature. This article is designed to help busy family physicians decide which qualitative studies are worth reading and to provide them with the tools to appreciate and evaluate research design and analysis. By using clinical analogies, the qualitative research process can be better understood.

Perceived causes of family physicians' errors.

BACKGROUND: Competent physicians occasionally make critical errors in patient care that can lead to long-lasting remorse and guilt. The perceived causes of self-admitted physician errors have not been previously explored. METHODS: Fifty-three family physicians were interviewed in depth and asked to describe their most memorable errors and the perceived causes. The authors analyzed transcripts of the audiotaped interviews to determine the frequencies of the different causes. Errors were classified according to four general categories. RESULTS: Family physicians collectively reported a mean of 8 different causes for each case in which an error was made (range, 1 to 16). In 47% of the cases, the patient died following the error, whereas in 26% of the cases, there was no adverse outcome. Only 4 of the 53 errors led to malpractice suits, and none were addressed by peer review organizations. Seven (10%) of the 70 physicians who were invited to participate could not recall having made any errors. Family physicians attributed their most memorable errors to 34 different causes, which fit into the following categories: physician stressors (eg, bing hurried or distracted), process-of-care factors (eg, premature closure of the diagnostic process), patient-related factors (eg, misleading normal findings), and physician characteristics (eg, lack of knowledge). CONCLUSIONS: Family physicians attribute their memorable errors to a wide variety of causes, but most commonly to hurry, distraction, lack of knowledge, premature closure of the diagnostic process, and inadequately aggressive patient management. Physicians who understand common causes of errors may be better prepared to prevent them.

Prevalence of cigarette and smokeless tobacco use among students in rural Oregon.

BACKGROUND: Although smoking and smokeless tobacco use are recognized as major problems among school-age youth, few studies report on tobacco use in rural areas, especially remote rural areas. METHODS: A self-report questionnaire was administered to all junior and senior high school students from a frontier rural community. RESULTS: A total of 393 students completed the questionnaire. Of the 393, 39% had tried chewing tobacco at least once. High school males were the heaviest users, and more than 50% of those males who had ever chewed were still current users (33% of the town's high school males). Seven percent of the town's high school females used chewing tobacco, one of the country's highest reported rates of use at the time of this study. In addition, 39% of all the students had also smoked cigarettes. High school females reported the highest prevalence of ever having smoked (52%) and also had the highest prevalence of current smoking (13.5%). The number of students who had ever tried any form of tobacco use and the number who were current users were significantly higher in the high school than the junior high school. More than half of the students who smoked or chewed reported having close friends who also use tobacco products. CONCLUSION: The high rate of female smokers and male chewers in senior high is consistent with other studies. The rate of female chewing tobacco use is unusually high. Isolated rural communities have significant adolescent tobacco abuse, and prevention and treatment strategies need to be developed for this special population.

Publication patterns of presentations at the Society of Teachers of Family Medicine and North American Primary Care Research Group annual meetings.

BACKGROUND AND OBJECTIVES: The annual meetings of the Society of Teachers of Family Medicine (STFM) and the North American Primary Care Research Group (NAPCRG) are important peer-reviewed venues for family medicine academicians to present their research. However, a relatively small number of individuals actually hear each presentation. In order to permanently share their research with a large number of peers, these presenters need to take the next step and publish completed manuscripts. This study examined the frequency with which presentations at these meetings are eventually published. METHODS: All abstracts from the 1987 and 1988 meetings of NAPCRG and the PEER and research sections of STFM were followed by performing a Medline computer search for the presenting author. Publications that matched the presentations were identified, and information was recorded about the elapsed time between presentation and publication, and the journal where publication occurred. RESULTS: Just under half (48%) of all the presentations were published within 4 or 5 years. There was no difference between 1987 and 1988 presentations, nor between NAPCRG and the combined STFM presentations. However, 69% of STFM research presentations were published compared to 31% of the peer presentations (X2 = 20.6, df = 2, P < .001). The STFM research publications also tended to be in print sooner than other presentations. Fifty-six percent of the publications occurred in family practice journals, with Family Medicine and the Journal of Family Practice being the most common journals. CONCLUSIONS: Approximately half of the presentations at STFM and NAPCRG annual meeting are published within 4 to 5 years. This is consistent with publication rates found for other specialty meetings. The reasons for not publishing are numerous and need to be better elucidated to help family medicine academicians complete the research loop and disseminate their findings to the scientific community.

Acute urinary tract infection in women. What kind of antibiotic therapy is optimal?

Urinary tract infections continue to be a major health problem for women. Understanding of the pathogenesis of urinary tract infections has improved; Staphylococcus saprophyticus has been recognized as a common causative agent, and low-colony-count infections are misdiagnosed less often. Traditional therapy with 10 days of amoxicillin (Amoxil, Wymox) or ampicillin (Omnipen, Totacillin) is no longer considered optimal. For women who fulfill certain clinical criteria, short-course therapy is recommended--preferably 3 days of trimethoprim-sulfamethoxazole, or trimethoprim alone (Proloprim, Trimpex) if the woman is allergic to sulfonamides. Longer therapy is indicated for women with complicated, prolonged, or recurrent infections. To appropriately treat patients and avoid overtreatment that would increase both costs and the incidence of side effects, physicians need to stay abreast of information about pathogens, mechanisms of disease, new drugs, and common resistance patterns.

Community attitudes and knowledge about advance care directives.

BACKGROUND: Patients and their physicians are increasingly being encouraged to discuss end-of-life decisions. The purpose of this study was to enhance understanding of the public's attitudes and knowledge about medical decision making and advance care directives. METHODS: Eight focus groups of community members discussed their understanding of and attitudes about advance care directives. Transcripts of these discussions were analyzed using coding categories created from the transcripts. RESULTS: Eighty-three people attended the focus groups. Most discussions of advance care directives involved family members in the setting of family or personal illness. Elderly persons commonly confused wills with living wills. Most who had given advance directives did so either to make others follow their wishes or to ease family burdens. Among the great variety of reasons for not using advance directives was a perceived lack of personal relevance, as well as conceptual, moral, and practical difficulties. Participants were divided about whether it was appropriate for physicians to initiate discussions about life-sustaining care with their patients. We discerned three themes affecting individuals' opinions about personal decision making about advance directives: (1) trust in family and the medical system, (2) need for control, and (3) knowledge about advance directives. CONCLUSIONS: Although living wills are advocated by many authorities, and many of our participants endorsed their use, our participants also cited numerous cautions and impediments to their use. As the role of advance care directives changes, physicians will need to be aware of their patients' perceptions, as well as the legalities of these documents.

Extrapulmonary tuberculosis. A review.

The increase in cases of tuberculosis that has occurred with the increasing number of individuals infected with the human immunodeficiency virus (HIV) has focused attention on the problems in diagnosing and treating tuberculosis. While it is primarily considered a pulmonary disease, tuberculosis has the potential to infect almost every organ system via lymphohematogenous dissemination during the initial pulmonary infection. Since 1984 the incidence of extrapulmonary tuberculosis has increased at an even faster rate than that of pulmonary tuberculosis. Extrapulmonary tuberculosis is considered a diagnostic criterion in the case definition of the acquired immunodeficiency syndrome. Immunocompromised individuals, such as patients with HIV, are at increased risk for extrapulmonary tuberculosis. The clinical manifestations are often nonspecific and insidious, and diagnosis may be delayed for years. Cases of miliary and meningeal tuberculosis are an exception, and they often constitute medical emergencies. Tuberculosis skin tests should be performed on all individuals suspected of having tuberculosis, but a negative test result does not exclude the diagnosis. Chest roentgenograms will often show signs of old or active pulmonary tuberculosis. Microscopic examination and culture of infected body fluids and/or tissue are necessary for definitive diagnosis. Treatment is with standard antituberculous medications. Short-course therapy (6 or 9 months) is probably adequate in most patients with extrapulmonary tuberculosis, but patients with human immunodeficiency viral infection need longer treatment. Extrapulmonary tuberculosis is a persistent problem in the United States and will become more prevalent as the number of patients with HIV increases. A high index of suspicion is needed to diagnose and treat extrapulmonary tuberculosis in a timely and health-preserving manner.

Abuse of skeletal muscle relaxants.

Centrally acting skeletal muscle relaxants are potential drugs of abuse. Although skeletal muscle relaxants are occasionally the primary drug of abuse, they are often used along with other central nervous system depressants, such as narcotics or alcohol. The major toxic effects are respiratory depression and coma. For the most part, the abuse problem is initiated and sustained iatrogenically. Physicians should be aware of the abuse potential of skeletal muscle relaxants.