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A Comparison of Medical Error Reports Submitted to a Voluntary Patient Safety Reporting System by Different Types of Reporters: A report from the ASIPS Collaborative. Daniel M. Harris, PhD, The CNA Corporation, Wilson Pace, MD & Doug Fernald, MA, Univ of CO DFM, - PowerPoint PPT Presentation
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CNACA Comparison of Medical Error Reports Submitted to a Voluntary Patient Safety Reporting System by Different Types of Reporters: A report from the ASIPS Collaborative
Daniel M. Harris, PhD, The CNA Corporation,Wilson Pace, MD & Doug Fernald, MA, Univ of CO DFM,
Linda Marr, MS, The CNA Corporation
AcademyHealth Annual Research MeetingJune 6, 2004
N
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Presentation outline
BackgroundResearch objectiveStudy design FindingsConclusions & implications
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Background Applied Strategies for Improving Patient Safety
(ASIPS) is a 3-yr AHRQ-funded demonstration project based at the Univ of CO Dept of Fam Med
Developed patient safety reporting system (PSRS) Collect voluntary narrative reports of medical errors from
providers, other clinical staff, and non-clinical staff at primary care practices in two CO PBRN
Anonymous or confidential-to-anonymous reports Instructed to report “any event you don’t wish to have
happen again that might represent a threat to patient safety”
Overall purpose of project is to test ability of the PSRS to collect incident reports and to use them to design interventions to improve patient safety
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Research objective Medical error reporting systems are advocated as a
strategy for improving patient safety Learning from errors requires receiving reports on repre-
sentative range of errors Limited evidence exists re: nature of events report-
ed to such systems by different reporter types, especially in ambulatory primary care settings Do different types tend to report different types of events?
Our objective is to (1) analyze reports submitted to ASIPS PSRS to ascertain “who reports what,” (2) identify similarities and differences in reports, and (3) characterize differentiating event attributes by reporter type
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Study design Error incident reports are received from 34 primary care
practices throughout Colorado Reports are consensually coded into multi-axial taxonomy of
400+ attributes by teams of coders Attributes characterize events by type of participants & their
contribution, complexity, setting, clinical intent, activities, under-lying causes, patient outcomes, interventions, and “discoverer”
Attributes are coded “1” if present in report; “0” if not present Reporters self-classified as provider, other clinical
staff, or non-clinical staff 522 (85.8%) of 608 reports received thru Aug 2003 identified a
reporter type Report content compared by reporter type using cross
tabs, ANOVA, and discriminant analysis
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Findings
Analysis of report Reports by reporter type Nature of report Event “discoverer”
Analysis of event reported Participants Patient harm Communication errors Other event characteristics Discriminant analysis
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Reports by reporter type
Most reports (68.6%) from providers Unchanged from yr1 to yr2
About 25% from other clinical staff Increased from yr1 to yr2
Fewest reports (6.9%) from non-clinical staff Deceased from yr1 to yr2
despite project effort to increase participation
Percent of Reports within Year, by Reporter Type
0
20
40
60
80
Prov Oth Clin Non-Clin
Total Yr 1 Yr 2
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Nature of report
No difference by reporter type: Patient gender Perceived prevent-
ability Perceived pt knows Mean taxonomy,
event activity, and “don’t know” codes
Differences by type:Patient age
• Mean lowest for non-clin; highest for provider
At least 1 “insufficient information” code
• Non-clin most likelyNoted in Med Rec’d
• Non-clin least likelyPerceived pt harm
• Oth clin least likely
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Event “discoverer”Providers & other clinical
staff likely to report events discovered by caregivers like themselves
Non-clinical staff likely to report events discovered by office staff like themselves
Providers somewhat less likely to report events discovered by patients or patient’s families
Percent of reports discovered by various parties, w/in reporter
type
0
20
40
60
80
100
Caregvr Ofc Staff Pt/Fam
Prov Oth Clin Non-Clin
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Event participants Each reporter type is
more likely to report an event with a participant of the same type All relationships statistically
significant by 2
No significant association by reporter type for other types of participants: Patient/family or 3rd party Number of participants or
number of participant types (by ANOVA)
Percent of reports with selected type of participants,
within reporter type
0102030405060
Prov Oth Clin Non-Clin
Prov Oth Clin Non-Clin
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Patient harmOverall, 26.4% of report-
ed events coded w/some form of patient harm Additional 7.7% of reports,
coded w/patient may have been harmed, but too early to tell
Significant differences in type of harm (by 2): Provider reports most
likely coded w/clinical harm
Non-clinical staff reports most likely coded with non-clinical harm
Other clinical staff reports least likely coded with any harm
Percent of reports coded with patient harm, w/in reporter
type
05
101520253035
Clin Harm Non-ClinHarm
Any Harm
Prov Oth Clin Non-Clin
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CommunicationOver half (57%) of reports
involve a communication error between parties Each reporter type likely to
report communication involving their own type
Oth clin staff less likely to report within office communication errors
Overall, non-clin staff less likely to report communication errors
Providers more likely to report communication involving patients
Percent of reports with communication errors
involving selected parties, w/in reporter type
0
10
20
30
40
50
Att ProvParty
Non-PhyParty
Ofc StaffParty
Prov Oth Clin Non-Clin
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Other event characteristics No difference by
reporter type: Missing information General proc issue Medication error Supervision error Intervention following
error detection Judgement error Clinical knowledge or
skill error Resource function or
availability error
Differences by type:Documentation
• Oth clin most likelySpecific proc issues
• Delay in Dx and Tx – prov most likely
• Delay in testing – oth clin staff most likely
• Dx testing error – non-clin least likely
Pt mgmt error• Non-clin most likely
Distraction/inattention• Prov least likely
System issue• Prov least likely
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Discriminant Analysis (1) Identify event attributes that differentiate be-
tween reports submitted by each reporter type Stepwise method: attributes enter that maximize
distance between 2 closest groups (16 of 32 entered) Resulting 2 discriminant functions differentiate
between the 3 reporter types• Group centroids are significantly different• Provider reports are most different from other 2 types
Canonical correlations (~ANOVA Eta) for the functions are .455 & .346; jointly account for 30% of variance in group scores
Discriminant scores correctly classify 63% of reports Classify unknown reports in similar proportion
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Discriminant Analysis (2) The analysis identified attributes that best discriminate
between events reported by each reporter group Provider reports most differentiated by:
provider participant, communication involving a provider, disclosure to a patient, delay in diagnosis, diagnostic testing error, and problem with resource (availability or function)
Other clinical staff reports most differentiated by: Non-physician provider participant, third party participant,
communication involving a provider, communication within the office, delay in performing a test, diagnostic testing error, and misuse of a system
Non-clinical staff reports most differentiated by: Non-clinical staff participant, non-clinical harm, error in patient
management, distraction/inattention error, misuse of a sys-tem, and malfunction of a system
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Conclusions
Different types of reporters tend to submit reports of different kinds of medical errors to a voluntary PSRS Each type of reporter tends to report errors
involving the kinds of activities and participants they can be most expected to observe and believe should be reported
For example:• Providers tend to report clinical harm events while non-
clinical staff tend to report non-clinical harm events• Providers tend to report events involving clinical proce-
dures while non-clinical staff tend to report patient management and system issue events
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Implications To be effective in identifying a full and repre-
sentative range of errors and threats to patient safety, a voluntary PSRS needs to assure that it receives incident reports from all types of staff (and patients?) who are in a position to observe errors Provider exclusive or dominated reporting systems
will restrict this range Our experience demonstrates the difficulty of
obtaining full participation of non-providers More effort necessary to achieve their participation
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Questions?
The CNA Corporation