Making Care Safe

Jane Stoever

A look at progress in studying medical errors seems fitting for the inaugural Annals of Family Medicine – and AAFP patient safety activities this spring in Washington, DC, provided plenty of grist for that mill.

“During the first few months after I came to this country from New Zealand in late 1999, I heard people saying things about health care that astonished me, and some of those things were about medical errors,” said Susan Dovey, PhD. She spoke March 18 at a primary care forum sponsored by the Robert Graham Center in Washington.

“Lots of things have changed in the last 3 years to make primary care safer,” Dovey said. She should know. She was principal investigator for the first US study of errors in family practice and was a coauthor of the first international study on errors in family practice/general practice.

Some things that astonished Dovey in early 2000:

The United States has “the best health system in the world,” said a participant in a briefing on Capitol Hill. Yet the World Health Organization listed healthy life expectancy at birth in the United States in 2000 as 67.4 years, a shorter healthy life span than experienced by people in 26 other countries.
At a meeting in Washington, Dovey heard, “Most health care is provided in hospitals.” But in 2001, the Robert Graham Center’s paper on the ecology of medical care showed that, for any 1000 people in the United States in a given month, 8 receive care in hospitals, and 217 visit physicians’ offices (of those, 113 visit primary care physicians’ offices).
As the Academy began to focus on medical errors, family physicians mentioned misplaced lab reports and messages left unanswered. Those, said Dovey, were regarded as “just trivial, everyday things – not what we mean by medical errors.”

The Institute of Medicine report To Err Is Human, issued in late 1999, focused on hospital settings and grabbed headlines with its estimate of 44,000 to 98,000 deaths per year from medical errors. In 2000, said Dovey, there was a leap in interest in studying threats to patient safety – with most of the studies in hospitals, but some in primary care.

By 2003, she said, “The scope of patient safety mistakes is better understood. Things that were considered trivial are now regarded as things to be corrected.”

She added, “Patient safety is recognized as an issue to be addressed at all levels of the health system.”

What have the Academy and the Robert Graham Center had to do with that? Lots. They’ve met these challenges:

Build an error reporting system. Family physicians in the AAFP National Network for Family Practice and Primary Care Research used a new system to record mistakes in their practices for the US study and are using it in other studies. Australia, Canada, Germany, New Zealand, the Netherlands, the United Kingdom and the United States are using the reporting system in their study group, called Learning in an International Network About Errors and Understanding Safety (LINNAEUS). The German team in the LINNAEUS group won the Berlin Health Medal this year for innovations in research. “That’s incredibly important to me, that a non-English-speaking country has won accolades for the work it’s done with us,” said Dovey.
Develop a description/categorization of the errors. Finding ways to label and count medical errors is a work in progress. Errors reported by the AAFP national research network and the LINNAEUS group led to a preliminary taxonomy. It lists process errors, such as mistakes in office administration, treatment, and communication, as well as knowledge and skills errors, such as errors in diagnosis and execution of a clinical task. “The categorization is now in use not only throughout the United States, but throughout the world,” said Dovey.
Test whether physicians could better use a paper reporting system or a computerized system. “We found that family physicians, even those unaccustomed to using computers in their daily practice, will use computers to report errors they see in their practice,” said Dovey.
Establish the Developmental Center for Research and Evaluation in Patient Safety in Primary Care. The center, a program of AAFP’s national research network, aims to improve the safety and quality of primary care through research, evaluation, education, and dissemination of research findings.
Put resources into developing effective, usable information technology systems for primary care offices. The Academy is exploring ways to develop, distribute and support an open-source electronic health record. The open-source model would lower physicians’ information technology costs by eliminating licensing fees and would allow users to contribute to the software’s evolution. The whole project would boost the quality of care, efficiency, and patient safety.
Receive recognition from funding agencies. For example, the AAFP national research network is conducting research through 2 grants from the Agency for Healthcare Research and Quality. One grant supports the study of laboratory and diagnostic imaging errors; the other funds research in medical errors reported by patients, physicians, and other staff in primary care.

“The AAFP is way ahead of the curve,” David Hsia, JD, MD, an analyst at AHRQ, said in response to Dovey’s talk. “You’re actually trying to collect data on patient safety. Most other specialties are not.”

The need for voluntary, confidential reporting systems for medical errors came under discussion March 13 during AAFP presentations for legislative aides and reporters on Capitol Hill.

The day before, the House of Representatives, by a vote of 418-6, passed HR 663, a bill that would give the green light to creating voluntary, confidential reporting systems for medical errors, including those in physicians’ offices. The entities collecting the data would be called patient safety organizations. (At press time, it was not known when the Senate might consider related legislation.)

The Academy held its 2 briefings to reinforce key elements of HR 663 and stress the importance of error reporting in primary care.

“This is not a new concept. Confidential, voluntary reporting is used by the Federal Aviation Administration for aviation safety, and it seems to work very well,” said AAFP President-elect Michael Fleming, MD, of Shreveport, La.

AAFP President James Martin, MD, of San Antonio, Tex, discussed medication mistakes and misfiled lab reports – mistakes often made and often discovered before a patient is harmed. “How many near misses take place in doctors’ offices that we never know about?” asked Martin. “This is not a time for fault-finding and finger-pointing. It is a time to try to identify where the errors occur and what it is that we require to make changes.”

Bob Phillips, MD, assistant director of the Robert Graham Center, explained, “We need organizations like the Academy to be able to become patient safety organizations and use their full engine – their full capacity for education, for tools for physicians’ practices – to improve patient care.”