The purpose of this study was to use published data from original research to understand and classify process errors and preventable adverse events associated with primary medical care. Through a systematic review and synthesis of the medical literature, we developed a classification of medical errors relevant to primary care.
Methods
To identify eligible published English-language original research articles, we searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH search term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care to the primary term. Published bibliographies from the National Patient Safety Foundation (NPSF) and the Institute for Healthcare Improvement (IHI) were also reviewed. The Web sites of the American Academy of Family Physicians, the American College of Physicians–American Society of Internal Medicine, the Institute of Medicine, the NPSF, and the IHI were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed, from seminal papers in the field, and from discussion with others working in the field of patient safety or quality improvement in primary care.
We reviewed titles of 379 articles identified by electronic searches for inclusion. We excluded papers if they related to comparisons of different approaches to diagnosis or treatment of specific diseases, the evaluation of teaching or research tools, or exclusively to hospitalized patients. If there was uncertainty as to the appropriateness of an article, we read the abstract. We reviewed complete papers if they appeared from the title and abstract to report original research involving a broad assessment of medical errors and preventable adverse events in primary care. Data relating to topic, study quality, and research results were abstracted from identified papers. Both authors performed independent MEDLINE searches and reviewed citations in the papers. To broaden the search for potential studies, one author searched Web sites and NPSF and IHI bibliographies. Both authors agreed on the inclusion of the chosen studies, appraised them independently, and abstracted key classification components. One author (N.C.E.) initially prepared the classification system presented here; it was then reviewed by both authors and revised after their discussions.
Results
Four original research studies directly studied and described medical errors and preventable adverse events in primary care.10-13 Three other studies peripherally addressed primary care medical errors as part of an investigation with another central focus14-16 (Table 1).
TABLE 1
Primary care studies describing medical error
| Study | Research purpose | Definition of error | Method | Pertinent results |
|---|---|---|---|---|
| Primary care studies directly describing medical error | ||||
| Bhasale et al10 | Describe incidents occurring in general practice | An unintended event, no matter how seemingly trivial or commonplace, that could have harmed or did harm a patient | Self-report by 324 Australian sentinel research network FPs using reporting cards | 805 incidents reported, 76% preventable; categories were drug management, non-drug management, diagnosis, and equipment; causes included communication, actions of others, and clinical judgment errors |
| Ely et al12 | Describe the causes to which family physicians attribute errors | Act or omission for which the physician felt responsible and which had serious consequences for the patient | 30-min interviews with 53 randomly chosen Iowa FPs | 53 errors reported: delayed diagnoses, surgical and medical treatment mishaps; causes included physical stressors, process of care factors, patient related factors, and physician characteristics |
| Dovey et al11 | Describe medical errors reported by FPs | Something in one’s practice that should not have happened, that was not anticipated, and that makes one say, “I don’t want it to happen again” | Self-report by 42 American research network FPs using electronic and reply card reporting | 330 reported errors, 83% from health care system and 13% from knowledge and skills; subcategories were office administration, investigations, treatments, communication, execution of clinical tasks, misdiagnosis, and wrong treatment decision |
| Fischer et al13 | Describe the prevalence of adverse events in a risk management database | Incidents resulting in, or having the potential for, physical, emotional, or financial liability for the patient | Review of incident reports entered by 8 primary care clinics into risk management database | Prevalence of adverse events was 3.7/100,000 clinic visits, 83% were preventable; categories included diagnostic, treatment, and preventive and other errors |
| Primary care studies peripherally describing medical error | ||||
| Holden et al15 | Determine patterns of death and potential preventive factors | Formal review of all patient deaths in a group of general practices | 5.1% of deaths due to preventable FP factors; 2 main categories were delay of diagnosis and treatment and lack of prevention with aspirin therapy | |
| Gandhi et al14communication | Evaluate primary care and specialist inter physician | Surveys in academic medical center | Main issues for doctors were lack of timeliness and inadequate content | |
| Britten et al16 | Describe misunderstandings between patients and FPs | Qualitative study using 5 data sources | 14 categories of misunderstandings were identified | |
| FP, family physician. | ||||