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Seeking to close a cavernous information gap, The Robert Graham Center for Policy Studies in Family Practice and Primary Care in Washington, DC, has launched a nationwide study of family physicians to identify medical errors in an ambulatory setting. According to the organization, most medical-error research to date has focused on inpatient information.
"I arrived in the U.S. [from New Zealand] in 1999, at about the same time as the Institute of Medicine’s To Err is Human1 study came out, and I was assigned to the topic of medical errors," recalls Susan Dovey, MPH, a Graham Center analyst and head investigator for the study. "I quickly became aware that virtually all discussion of medical errors is focused on hospital care. But our organization’s focus is primary care."
In fact, Dovey’s initial efforts involved a major study of exactly where people encounter the health care system in the United States, which was when she discovered that 25 times as many people in this country have experiences with office-based providers than with hospital-based providers. "This sort of crossed over into the current study," Dovey explains. "Everyone talks about medical errors in terms of problems such as wrong-sided surgery, but relatively very few people have those sorts of problems."
Dovey is clear that one of her goals is to fill an information gap in the medical literature.
Linda C. Stone, MD, president of the Ohio Academy of Family Physicians and a member of the faculty at The Ohio State University in Columbus, says Dovey’s on the right track.
"There’s currently a big push in family medi-cine," she says. "But if we’re really going to advocate for our patients, we need to have practice-based research. Most of our patients don’t go to the hospital. We should be looking at our outcomes. Are we proving over time that the things we’re doing continue to work? At Ohio State, our big push is practice-based research, to in turn make sure our ongoing family practices are evidenced-based."
In all, 42 family physicians filled in Dovey’s data form between May and August 2000. She is adamant about the fact that the focus of her study is errors. "People often confuse terms," she explains. "For example, there are adverse events, which may or may not be due to a mistake. A certain number of people will always have an adverse reaction to the right’ medication.
"Then there are critical incidents, or near-misses, which are sometimes adverse events but not always. Then you must distinguish between mistakes and medical errors; there can be times when the wrong thing clearly happened, but it may or may not result in an adverse outcome. We were very focused on medical errors," Stone says.
She also makes it clear that all errors merit attention. "Little errors sometimes progress and kill people," she notes. "Hospital protocols can help prevent that kind of progression, but there are no equivalents for primary care or for laboratory tests. That’s why we needed to collect these data." (The progression of a little error can result in what Dovey calls a "Toxic Cascade." See "Survey leads to new model for illustrating errors," in this issue.)
Whatever the survey turns up, Stone says all errors will be divisible into what she calls "two piles:" low-tech and high-tech errors. "To me, the most important is low-tech. As family physicians, the most important thing we establish with a patient is a relationship. If we communicate really well back and forth, that will be the first big step to eliminating errors. If you go where the patients are, you will serve them better."
For example, she says, when you tell patients the tests show they have cancer, you must be aware they will hear nothing else you say, which makes it that much more critical to write down your discussion. "The patient will get home and not remember what to tell family members."
As for the high-tech role in eliminating errors, Stone encourages her patients to explore the Internet. "They will feel empowered to communicate with you. Otherwise, they may miss pieces of information and be sent down the wrong path."
Dovey says her hopes for future studies reflect a similar respect for the collaborative role between patient and physician.
"Our current study is only from the doctor’s world view," she admits. "Studies also need to be done from the patient’s world view and from the clinician’s world view."
[For more information, contact:
Susan Dovey, MPH, The Robert Graham Center for Policy Studies in Family Practice and Primary Care, 2023 Massachusetts Ave. N.W., Washington, DC 20036. Telephone: (202) 986-5708. Fax: (202) 986-7034. E-mail: firstname.lastname@example.org.
Linda C. Stone, MD, The Ohio State University, 456 W. 10th Ave., Room 1114, Columbus, OH 43210. Telephone: (614) 293-7099.]
1. Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.