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Learning From Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients: A Project of the American Academy of Family Physicians National Research Network

Phillips, Robert L. MD, MSPH; Dovey, Susan M. MPH, PhD; Graham, Deborah MSPH; Elder, Nancy C. MD, MSPH; Hickner, John M. MD, MS

doi: 10.1097/01.jps.0000235385.93406.d4
Original Articles

Objectives: To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report.

Methods: Clinicians, staff, and patients in 10 family medicine clinics of the American Academy of Family Physicians National Research Network representing a diversity of clinical and community settings were invited to report errors they observed. They were asked to report routinely during 10 weeks and to report every error on 5 specific days. They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system.

Results: Four hundred one clinicians and staff reported 935 errors within 717 events, 37% (265) of which came from the 5 intensive reporting days and 61% (440) from routine reports. Staff made 384 (53%) reports, and clinicians, 342 (47%) reports. Most (96%) errors reported were process errors, not related to knowledge or skill. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Reports suggest that patients with complex health issues (31% versus 20%, P = 0.013) are vulnerable to more severe outcomes. Patients submitted 126 reports, 18 of which included errors.

Conclusions: Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors. There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff.

From the *The Robert Graham Center: Policy Studies in Family Medicine and Primary Care, Washington, District of Columbia; †Royal New Zealand College of General Practitioners Research Unit, Dunedin, New Zealand; ‡American Academy of Family Physicians National Research Network, Leawood, Kansas; §University of Cincinnati Department of Family Medicine, Cincinnati, Ohio; and ∥University of Chicago Department of Family Medicine, Chicago, Illinois.

Correspondence: Robert L. Phillips, MD, MSPH, The Robert Graham Center: Policy Studies in Family Medicine and Primary Care, 1350 Connecticut Ave, NW, Suite 201, Washington, DC 20036 (e-mail: bphillips@aafp.org).

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