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.
BACKGROUND
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.


METHODS
Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting.


METHODS
243 clinicians and office staff of eight family medicine offices.


METHODS
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.
Department of Family Medicine, The University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 7110, Suite M-156, Chicago, IL 60637-1470, USA. jhickner@uchicago.edu
J
J
Hickner
D G
DG
Graham
N C
NC
Elder
E
E
Brandt
C B
CB
Emsermann
S
S
Dovey
R
R
Phillips
D000704:Analysis of Variance; D015982:Bias; D002983:Clinical Competence; D019411:Clinical Laboratory Techniques / Q000706:statistics & numerical data; D019937:Diagnostic Techniques and Procedures / Q000706:statistics & numerical data*; D005194:Family Practice / Q000458:organization & administration*; D005260:Female; D006302:Health Services Research; D006801:Humans; D016015:Logistic Models; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data; D012308:Risk Management