Medication errors reported by US family physicians and their office staff.

BACKGROUND: Most medication error studies come from inpatient settings. There is limited information about medication errors in primary care settings. OBJECTIVE: To describe medication errors reported by family physicians and their office staff and to estimate their preventability using currently available electronic prescribing and monitoring tools. Design, setting, participants and study instrument: In two error reporting studies conducted by the American Academy of Family Physicians (AAFP) National Research Network (NRN), 1265 medical errors were voluntarily reported by >440 primary care clinicians and staff from 52 physician offices. The 194 error reports related to medications were abstracted and analysed using a medication error coding tool-Medication Error Types, Reasons, and Informatics Preventability (METRIP). MAIN OUTCOME MEASURES: Type, severity and preventability of medication errors and associated adverse drug events (ADEs). RESULTS: 126 (70%) of the medication errors were prescribing errors, 17 (10%) were medication administration errors, 17 (10%) documentation errors, 13 (7%) dispensing errors and 5 (3%) were monitoring errors. ADEs resulted from 16% of reported medication errors. The severity of harm from reported errors were: prevented and did not reach patients, (72, 41%), reached patients but did not require monitoring (63, 35%), reached patients and required monitoring (15, 8%), reached patients and required intervention (23, 13%) and reached patients and resulted in hospitalisation (5, 3%). No deaths were reported. Of the errors that were prevented from reaching patients, 29 (40%) were prevented by pharmacists, 14 (19%) by physicians, 12 (17%) by patients and 5 (7%) by nurses. 102 (57%) of the reported errors might have been prevented with enhanced electronic prescribing and monitoring tools. CONCLUSIONS: Most medication errors reported from US family physician offices were related to prescribing errors and more than half of the errors reached patients. The errors were prevented by pharmacists, patients and physicians. More than half of the errors could be prevented by electronic tools.

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.

A randomized controlled trial of telephone management of suspected urinary tract infections in women.

OBJECTIVE: Although urinary tract infections (UTIs) in otherwise healthy ambulatory women are often managed over the telephone, there has been no systematic evaluation of this approach. Our objective was to compare the outcomes of uncomplicated UTIs in healthy women managed over the telephone with those managed in the office. STUDY DESIGN: We randomly assigned women calling their usual provider with a suspected UTI to receive care over the telephone (n=36) or usual office-based care (n=36). All women had urinalyses and urine cultures. All were treated with 7 days of antibiotics. We compared symptom scores at baseline and at day 3 and day 10 after therapy. We also compared patient satisfaction at the end of the study. The settings were family practices in Michigan. POPULATION: We included healthy nonpregnant women older than 18 years. RESULTS: A total of 201 women with suspected UTIs called their physician. Of these, 99 were ineligible, and 30 declined to participate. The women were young (mean age=36.6 years) and predominantly white (86%). Sixty-four percent of the urine cultures had significant growth of a single organism. We observed no difference in symptom scores or satisfaction. Overall, satisfaction was high. CONCLUSIONS: Short-term outcomes of managing suspected UTIs by telephone appear to be comparable with usual office care.

Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods.

The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions--especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)--a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections, the Centers for Disease Control and Prevention convened a panel of physicians representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases to develop a series of "Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults." These principles provide evidence-based recommendations for evaluation and treatment of adults with acute respiratory illnesses.This paper describes the background and specific aims of and methods used to develop these principles. The goal of the principles is to provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. These principles should be used in conjunction with effective patient educational campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of the conditions in question.

Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background.

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. 1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare. 3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background.

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever. Sinus radiography is not recommended for diagnosis in routine cases. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

Principles of appropriate antibiotic use for acute pharyngitis in adults: background.

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus. 1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed. 2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care. 3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: (a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; (b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or (c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered. 5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background.

The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated. Patient satisfaction with care for acute bronchitis depends most on physician--patient communication rather than on antibiotic treatment.

Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods.

The need to decrease excess antibiotic use in ambulatory practice has been fueled by the epidemic increase in antibiotic-resistant Streptococcus pneumoniae. The majority of antibiotics prescribed to adults in ambulatory practice in the United States are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upper respiratory tract infections (including the common cold). For each of these conditions-especially colds, nonspecific upper respiratory tract infections, and acute bronchitis (for which routine antibiotic treatment is not recommended)-a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Because decreasing community use of antibiotics is an important strategy for combating the increase in community-acquired antibiotic-resistant infections, the Centers for Disease Control and Prevention convened a panel of physicians representing the disciplines of internal medicine, family medicine, emergency medicine, and infectious diseases to develop a series of "Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults." These principles provide evidence-based recommendations for evaluation and treatment of adults with acute respiratory illnesses.This paper describes the background and specific aims of and methods used to develop these principles. The goal of the principles is to provide clinicians with practical strategies for limiting antibiotic use to the patients who are most likely to benefit from it. These principles should be used in conjunction with effective patient educational campaigns and enhancements to the health care delivery system that facilitate nonantibiotic treatment of the conditions in question.

Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults: background.

The following principles of appropriate antibiotic use for adults with nonspecific upper respiratory tract infections apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.1. The diagnosis of nonspecific upper respiratory tract infection or acute rhinopharyngitis should be used to denote an acute infection that is typically viral in origin and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. 2. Antibiotic treatment of adults with nonspecific upper respiratory tract infection does not enhance illness resolution and is not recommended. Studies specifically testing the impact of antibiotic treatment on complications of nonspecific upper respiratory tract infections have not been performed in adults. Life-threatening complications of upper respiratory tract infection are rare.3. Purulent secretions from the nares or throat (commonly observed in patients with uncomplicated upper respiratory tract infection) predict neither bacterial infection nor benefit from antibiotic treatment.

Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background.

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised.1. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. 2. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever.3. Sinus radiography is not recommended for diagnosis in routine cases. 4. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

Principles of appropriate antibiotic use for acute pharyngitis in adults: background.

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.1. Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b) test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered.5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background.

The following principles of appropriate antibiotic use for adults with acute bronchitis apply to immunocompetent adults without complicating comorbid conditions, such as chronic lung or heart disease.1. The evaluation of adults with an acute cough illness or a presumptive diagnosis of uncomplicated acute bronchitis should focus on ruling out serious illness, particularly pneumonia. In healthy, nonelderly adults, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is usually not indicated. In patients with cough lasting 3 weeks or longer, chest radiography may be warranted in the absence of other known causes.2. Routine antibiotic treatment of uncomplicated acute bronchitis is not recommended, regardless of duration of cough. If pertussis infection is suspected (an unusual circumstance), a diagnostic test should be performed and antimicrobial therapy initiated.3. Patient satisfaction with care for acute bronchitis depends most on physician-patient communication rather than on antibiotic treatment.

Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network.

BACKGROUND: Antibiotics are often prescribed for viral respiratory infections. The goal of our study was to determine the factors associated with antibiotic prescribing for acute respiratory infections in primary care. METHODS: We performed an observational study in 15 primary care practices in Michigan using patient and physician surveys distributed during visits for acute respiratory infections. We included patients 4 years or older presenting with symptoms of an acute respiratory infection (n=482). The main outcome measures were prescriptions of antibiotics, signs and symptoms associated with antibiotic prescribing, and clinician-reported reasons for prescribing an antibiotic. RESULTS: We found that patients who were older than 18 years, sick for more than 14 days, and seen in urgent care clinics were more likely to receive antibiotics. Patients expected antibiotics if they perceived that the drug had helped with similar symptoms in the past. In an adjusted model, the variables significantly associated with antibiotic prescribing were physical findings of sinus tenderness (odds ratio [OR]=20.0; 95% confidence interval [CI], 8.3-43.2), rales/rhonchi (OR=19.9; 95% CI, 9.2-43.2), discolored nasal discharge (OR=11.7; 95% CI, 4.3-31.7), and postnasal drainage (OR=3.1; 95% CI, 1.6-6.0). The presence of clear nasal discharge on examination was negatively associated (OR=0.3; 95% CI, 0.2-0.5). CONCLUSIONS: Several physical signs play an important role in clinicians' decisions to prescribe antibiotics for respiratory infections. This information will be useful in designing interventions to decrease inappropriate antibiotic prescribing for upper respiratory infections.

High prevalence of overweight children and adolescents in the Practice Partner Research Network.

OBJECTIVES: To determine the prevalences of overweight children and adolescents seeking care in 49 Practice Partner Research Network (PPRNet) primary care practices and to compare these rates with national population-based surveys. DESIGN AND SETTING: The prevalence of overweight subjects (>95th percentile for age and sex) and subjects at risk for being overweight (>85th percentile for age and sex) was calculated for 30445 children aged 6 through 19 years visiting PPRNet primary care practices from 1995 through 1997. Prevalences were compared with prevalences from the National Health and Nutrition Examination Surveys. Percentile cutoffs from the National Health Evaluation Survey were used as the baseline standard for the comparisons. MAIN OUTCOME MEASURE: Obesity prevalences. RESULTS: Thirty-six percent of boys aged 6 through 11 years and 35% of boys aged 12 through 17 years were either at risk for being overweight or overweight; 20% and 19% were overweight, respectively. Thirty-five percent of girls aged 6 through 11 years and 34% of girls aged 12 through 17 years were either at risk for being overweight or were overweight; 20% and 18% were overweight, respectively. Prevalences of overweight subjects and subjects at risk for being overweight were much greater in patients of PPRNet primary care practices compared with the most recent national survey, the National Health and Nutrition Examination Surveys III. CONCLUSIONS: One in 3 children and adolescents visiting PPRNet primary care practices is at risk for being overweight or is overweight. The prevalence of obesity in children and adolescents visiting primary care practices is much greater than that observed in national population-based surveys.

High prevalence of overweight children in Michigan primary care practices. An UPRNet study. Upper Peninsula Research Network.

BACKGROUND: Our goal was to determine whether the prevalence of obesity in children who receive care in Michigan primary care practices is greater than national and state prevalences. METHODS: We compared prevalences of overweight children and adolescents in primary care practices with the results of the National Health Examination Survey (NHES), the National Health and Nutrition Examination surveys, and a contemporary survey of Michigan schoolchildren. We collected data from 19 rural family practice offices and 2 urban clinics. We measured the heights and weights of 993 consecutive patients aged 4 to 17 years who visited one of the participating practices during the spring of 1996. RESULTS: Obesity prevalences were the main outcome measure. Of the boys, 38% were above the 85th percentile of the NHES, and 16% were above the 95th percentile. Of the girls, 33% were above the 85th percentile, and 13% were above the 95th percentile. Prevalences of obesity were much higher among the primary care patients than in the results of the national surveys and the contemporary Michigan schoolchildren survey. CONCLUSIONS: The prevalences of obesity for children and adolescents presenting for care in Michigan primary care practices are higher than the prevalences documented in state and national surveys. A larger systematic study is needed to confirm or refute these findings. If this prevalence of obesity in primary care patients is confirmed, explanations for the differences should be explored.