Informing the Design of a New Pragmatic Registry to Stimulate Near Miss Reporting in Ambulatory Care.
Journal
Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393
Informations de publication
Date de publication:
01 04 2021
01 04 2021
Historique:
pubmed:
2
3
2017
medline:
25
11
2021
entrez:
2
3
2017
Statut:
ppublish
Résumé
Ambulatory care safety is of emerging concern, especially in light of recent studies related to diagnostic errors and health information technology-related safety. Safety reporting systems in outpatient care must address the top safety concerns and be practical and simple to use. A registry that can identify common near misses in ambulatory care can be useful to facilitate safety improvements. We reviewed the literature on medical errors in the ambulatory setting to inform the design of a registry for collecting near miss incidents. This narrative review included articles from PubMed that were: 1) original research; 2) discussed near misses or adverse events in the ambulatory setting; 3) relevant to US health care; and 4) published between 2002 and 2013. After full text review, 38 studies were searched for information on near misses and associated factors. Additionally, we used expert opinion and current inpatient near miss registries to inform registry development. Studies included a variety of safety issues including diagnostic errors, treatment or management-related errors, communication errors, environmental/structural hazards, and health information technology (health IT)-related concerns. The registry, based on the results of the review, updates previous work by including specific sections for errors associated with diagnosis, communication, and environment structure and incorporates specific questions about the role of health information technology. Through use of this registry or future registries that incorporate newly identified categories, near misses in the ambulatory setting can be accurately captured, and that information can be used to improve patient safety.
Identifiants
pubmed: 28248748
pii: 01209203-202104000-00015
doi: 10.1097/PTS.0000000000000317
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e121-e127Informations de copyright
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors disclose no conflict of interest.
Références
Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care [Internet]. 2015. Available at: https://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx . Accessed January 20, 2016.
Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. 2011 Available at: https://www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx . Accessed March 30, 2014.
Marks CM, Kasda E, Paine L, et al. “That was a close call”: endorsing a broad definition of near misses in health care. Jt Comm J Qual Patient Saf . 2013;39:475–479.
Wu AW. The value of close calls in improving patient safety: learning how to avoid and mitigate patient harm. Joint Commission Resources: Oak Brook, IL; 2011.
Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System . Washington, D.C: National Academy Press; 2000.
Agency for Healthcare Research and Quality. AHRQ’s Patient Safety Initiative: Building Foundations, Reducing Risk: Chapter 1. Available at: http://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psini1.html . Accessed March 22, 2015.
Schultz TJ, Crock C, Hansen K, et al. Piloting an online incident reporting system in Australasian emergency medicine. Emerg Med Australas . 2014;26:461–467.
Chang A, Schyve PM, Croteau RJ, et al. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care . Oxford University Press. 2005;17:95–105.
ACP Near Miss Registry. Available at: http://www.acponline.org/newsroom/near_miss_registry.htm . Accessed March 22, 2015.
Agency for Healthcare Research and Quality. Common Format. Available at: http://www.pso.ahrq.gov/common . Accessed March 2, 2013.
Centers for Medicare and Medicaid. AHRQ Common Formats—Information for Hospitals and State Survey Agencies (SAs)—Comprehensive Patient Safety Reporting Using AHRQ Common Formats. 2013. Available at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-19.pdf . Accessed May 1, 2014.
American College of Physicians. Near Miss Registry. Available at: https://www.acponline.org/running_practice/quality_improvement/near_miss/ . Accessed March 27, 2015.
Preventing errors in the outpatient setting: a tale of three states. Health Aff (Millwood). Project HOPE—The People-to-People Health Foundation, Inc; 2002 Jul;21(4):26–39.
American College of Physicians. ACP—New York State Chapter Partnership Results in Patient Safety Organization Recognition. 2012. Available at: http://www.acponline.org/newsroom/near_miss_registry.htm . Accessed March 22, 2015.
Kivlahan C, Sangster W, Nelson K, et al. Developing a comprehensive electronic adverse event reporting system in an academic health center. Jt Comm J Qual Improv . 2002;28:583–594.
Elder NC, Dovey SM. Classification of medical errors and preventable adverse events in primary care: a synthesis of the literature. J Fam Pract . 2002;51:927–932.
ECRI Reporting System. Pennsylvania Patient Safety Reporting System. Available at: http://www.patientsafetyauthority.org/PA-PSRS/Pages/PAPSRS.aspx . Accessed March 22, 2015.
Centers for Disease Control and Prevention. Fastats Doctors Visit. Available at: http://www.cdc.gov/nchs/fastats/physician-visits.htm . Accessed March 30, 2014.
Centers for Disease Control and Prevention. Fastats Hospital. Available at: http://www.cdc.gov/nchs/fastats/hospital.htm . Accessed March 30, 2014.
American Medical Association. Research in Ambulatory Patient Safety. 2000–2010: A 10-year review. Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=23742 . Accessed March 30, 2014.
Schwartz MD. Health Care Reform and the Primary Care Workforce Bottleneck. J Gen Intern Med . 2012;27:469–472.
Hsiao CJ, Hing E. Use and Characteristics of Electronic Health Record Systems Among Office-based Physician Practices . United States: 2001–2012:2012.
McDonald KM, Schultz E, Albin L, et al. Care Coordination Measures Atlas. Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/ccm_atlas.pdf . Accessed March 30, 2014.
Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med . 2006;145:488–496.
McLeod L, Kingston-Riechers J, Jonsson E. A conceptual framework identifying sources of risk to patient safety in primary care. Aust J Prim Health . 2012;18:185–189.
Kuo GM, Phillips RL, Graham D, et al. Medication errors reported by US family physicians and their office staff. Qual Saf Health Care. BMJ Publishing Group Ltd. 2008:286–290.
Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. CMAJ . 2003;169:549–556.
Buck MD, Atreja A, Brunker CP, et al. Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health records. Am J Geriatr Pharmacother . 2009;7:84–92.
Abramson EL, Barrón Y, Quaresimo J, et al. Electronic prescribing within an electronic health record reduces ambulatory prescribing errors. Jt Comm J Qual Patient Saf . 2011;37:470–478.
Wessell AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. Am J Geriatr Pharmacother . 2008;6:21–27.
Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc . BMJ Publishing Group Ltd. 2012:644–648.
Wisniewski AM, Luczkiewicz DL, Servoss TJ, et al. What happens to orders written for older primary care patients? Fam Med . 2012;44:252–258.
Elder NC, McEwen TR, Flach J, et al. The management of test results in primary care: does an electronic medical record make a difference? Fam Med . 2010;42:327–333.
Elder NC, Vonder Meulen M, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Ann Fam Med . 2004;2:125–129.
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary care. BMJ Qual Saf . BMJ Publishing Group Ltd. 2012;21:30–38.
Singh H, Thomas EJ, Khan MM, et al. Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med . 2007;167:302–308.
Ely JW, Kaldjian LC, D’Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med American Board of Family Medicine. 2012;25:87–97.
Singh H, Giardina TD, Meyer AN. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med . 2013;173:418–425.
Woods DM, Thomas EJ, Holl JL. Ambulatory care adverse events and preventable adverse events leading to a hospital admission. Qual Saf Health Care . BMJ Publishing Group Ltd. 2007;16:127–131.
Singh H, Giardina TD, Forjuoh SN, et al. Electronic health record-based surveillance of diagnostic errors in primary care. BMJ Qual Saf . BMJ Publishing Group Ltd. 2012:93–100.
Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA . 2003;289:1107–1116.
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med . 2003;348:1556–1564.
Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with outpatient computerized prescribing systems. J Am Med Inform Assoc . BMJ Publishing Group Ltd. 2011;18:767–773.
Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med . 2004;164:305–312.
Zhan C, Correa-de-Araujo R, Bierman AS, et al. Suboptimal prescribing in elderly outpatients: potentially harmful drug-drug and drug-disease combinations. J Am Geriatr Soc. Blackwell Science Inc;2005 :262–267.
Elston Lafata J, Simpkins J, Kaatz S, et al. What do medical records tell us about potentially harmful co-prescribing? Jt Comm J Qual Patient Saf . 2007;33:395–400.
Singh H, Thomas EJ, Sittig DF, et al. Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain? Am J Med . 2010;123:238–244.
Moore C, Wisnivesky J, Williams S, et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med . 2003;18:646–651.
Fischer SH, Tjia J, Field TS, et al. Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review. J Am Med Inform Assoc . BMJ Publishing Group Ltd. 2010;17:631–636.
Dainty KN, Adhikari NKJ, Kiss A, et al. Electronic prescribing in an ambulatory care setting: a cluster randomized trial. J Eval Clin Pract . Blackwell Publishing Ltd. 2012:761–767.
Abramson EL, Pfoh ER, Barrón Y, et al. The effects of electronic prescribing by community-based providers on ambulatory medication safety. Jt Comm J Qual Patient Saf . 2013;39:545–552.
Singh R, Servoss T, Kalsman M, et al. Estimating impacts on safety caused by the introduction of electronic medical records in primary care. Inform Prim Care . 2004;12:235–242.
Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. Arch Intern Med . 2011;171:1281–1284.
Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf . 2008;34:36–45.
Newman-Toker DE, Pronovost PJ. Diagnostic errors—the next frontier for patient safety. JAMA American Medical Association . 2009 Mar 11;301:1060–1062.
Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf . BMJ Publishing Group Ltd. 2015;24:103–110.