Safety/Quality

Voluntary primary care safety reporting system includes errors due to communication, diagnostic tests, and medication

Most efforts to improve patient safety have focused on reducing hospital errors. However, errors in primary care also may have serious consequences. A recently implemented primary care safety reporting system (Applied Strategies for Improving Patient Safety, ASIPS)—which encourages clinicians and staff to report errors or near misses either anonymously or confidentially—helps to pinpoint some major causes of errors.

During the first 2 years of the project, more than 700 error reports were submitted. Problems in communication (71 percent), diagnostic tests (47 percent), medications (35 percent), and both diagnostic tests and medications (14 percent) made up most error reports to the system.

Compared with anonymous reports, confidential reports to the system yielded richer information on which to base safety improvements. In the confidential reports, the reporters identified themselves and were interviewed, but all contact information was automatically expunged from the database within 10 days after report submission.

Researchers from the University of Colorado Health Sciences Center and the CNA Corporation, Alexandria, VA, examined the types of medical error reports submitted to the system from clinicians and staff in two practice-based research networks: The Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN). The study was supported by the Agency for Healthcare Research and Quality (HS11878).

Participants were asked to report "any event you don't wish to have happen again that might represent a threat to patient safety" (including near misses where no patient harm actually occurred). During the first 2 years of the project, 33 practices with a total of 475 clinicians and staff participated in ASIPS. Participants submitted 708 reports during this time, with two-thirds of participants using the confidential reporting form. The researchers followed up on 84 percent of the confidential reports within the allotted 10-day time frame and ended up with 608 relevant, codable reports.

See "Event reporting to a primary care patient safety reporting system: A report from the ASIPS collaborative," by Douglas H. Fernald, M.D., Wilson D. Pace, M.D., Daniel M. Harris, Ph.D., and others, in the July 2004 Annals of Family Medicine 2(4), pp. 327-332.

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