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Service Delivery Innovation Profile

Voluntary Error Reporting Program Focusing on Systems Issues Increases Reporting and Contributes to Reduction in Liability Claims at Outpatient Clinic


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Snapshot

Summary

A hospital outpatient clinic developed a confidential, voluntary error reporting system that focuses on identifying faulty systems and error-prone areas—instead of individual mistakes—to improve processes and prevent future mistakes. A simple taxonomy of errors was created to track the types of issues that were identified. Since implementing the system, the number of error reports increased sixfold (from 20 to 120), while the number of liability claims has declined. Although there is no direct evidence linking the system to the reduction in liability claims, program leaders believe it has been a contributing factor to the decline.

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre- and post-implementation data on the number of error reports and liability claims, but there is no statistical evidence that confirms that the drop in liability claims resulted from the improvements inspired by the error reporting system. HEDIS® measures were not regularly tracked until after implementation of the error reporting system.
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Developing Organizations

Duke University Medical Center Department of Community and Family Medicine
Durham, NCend do

Use By Other Organizations

The Department of Community and Family Medicine in Durham has had two inquiries from programs outside of Duke. They have also had other departments/divisions within Duke ask about the program. The system has been used by other divisions within the Duke Department of Community and Family Medicine.

Date First Implemented

2005
An early version of the system was launched in 1997, with significant refinements made in 2005.

Problem Addressed

Although patient safety has received significant attention in the inpatient setting, relatively few attempts have been made to identify and address the many preventable errors that occur in outpatient settings. Many barriers exist to the reporting of errors in this setting, and few organizations have attempted to reduce these barriers by developing voluntary, nonpunitive reporting systems.
  • Outpatient errors a common occurrence: In one study of 351 outpatient visits at seven family practice clinics, errors and preventable adverse events were identified in 24 percent of visits. There was wide variation in how often individual physicians identified errors, ranging from 3 to 60 percent of visits. Office administration errors were the most frequent; harm was believed to have occurred as a result of 24 percent of the errors, and was a potential in another 70 percent.1 A separate study found that the two most common errors reported by U.S. family physicians relate to prescribing and dispensing medications and ordering and executing appropriate laboratory tests.2
  • Errors are often preventable: Studies have found that most errors in primary care practice are preventable. One study of eight primary care clinics found that 83 percent of medical errors were preventable, with diagnostic (representing 26 percent of preventable errors) and treatment errors (31 percent) being the most common preventable mistakes.3
  • Significant barriers to reporting medical errors: Barriers to reporting errors in family medicine practices include the burden of making a report, confusion about what information to include in an error report, the perceived benefit and risk to the reporter, and confusion about how to describe the causes of the error.4 Another disincentive is the perception that reporting will not result in any improvement.
  • Underuse of voluntary reporting systems: Overcoming these barriers requires a simple, voluntary reporting system and a process that emphasizes that information gathered will be used to improve the practice environment and not punish individuals.4 Voluntary reporting systems typically focus on near-misses or errors that result in minimal patient harm but indicate systemic or departmental weaknesses in health care delivery that need to be addressed. But few health care organizations have these kind of nonpunitive, voluntary reporting systems in place.5

What They Did

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Description of the Innovative Activity

The Duke University Medical Center Department of Community and Family Medicine in Durham, NC, developed a voluntary system that encourages the reporting of errors, concerns, and near-misses in a nonpunitive manner; the goal of the program is to identify and address systemic problems to prevent future errors. Reports are confidentially analyzed by a peer review committee to identify and address any systemic patterns and/or faulty systems. Highlights of the error reporting system are described below:
  • Positioning the system to encourage reporting: Because fear of “betraying” colleagues is a disincentive to error reporting, Duke positions the system as designed to report “concerns” rather than “errors,” which takes the burden of judgment off the reporter. Self-reporting of unexpected outcomes or near misses is strongly encouraged.
  • Submission of error reports: Providers submit reports in hard copy using a double-sided form that asks for a description of the issue, patient identification information (if necessary), the urgency of the action needed, and what actions, if any, were taken when the error occurred. Drop boxes for error reports are available in all clinic workrooms. Alternatively, reporters may send a confidential e-mail to the Quality Improvement coordinator. All reporters identify themselves. Reports may be quite brief (noting the patient identification number and date, and providing a sentence or less describing the concern) or detailed. The majority of error reports come from physicians and physician assistants, with fewer reports coming from nurses and front desk staff. Some practitioners report events that they were involved in, while others do not feel comfortable doing so. To date, no error reports have been requested from patients.
  • Tracking of error types: To assist in identifying patterns and trends in errors, the following taxonomy of error categories was developed. This is included on the form for use by reporters:
    • Communication: These errors relate to problems in interactions between providers and patients or their relatives, or between providers and other providers or staff members.
    • Studies and laboratory tests: These errors include ordering a wrong or unindicated test, not ordering an indicated test, problems in reporting results to providers, problems in responding to results, and other related problems.
    • Diagnosis: These errors include insufficient evaluation for the diagnosis, a wrong and/or missed diagnosis based on available data, and other issues.
    • Medication: These errors include ordering the wrong medication, dose, or an unindicated drug; not ordering an indicated drug; not delivering or administering a drug as ordered; and other issues.
    • Other treatment or followup (excluding diagnostic studies and medications): These errors include ordering something incorrectly, such as the wrong treatment, wrong timing, or an unindicated treatment; not ordering a treatment when indicated; not delivering or completing a treatment as ordered; and other issues.
    • Records: These errors include incomplete or incorrect records.
    • Administration: These errors relate to the handling and transmission of messages, problems in appointment scheduling, and other administrative errors.
    • Other reports: This category includes adverse outcomes, unhappy patients, problems related to patient choice, and other issues not captured elsewhere.
  • Quality improvement review committee review of reports and other significant events: The reports are logged into a secure, confidential database and circulated in confidential packets to a quality improvement peer review team made up of doctors, nurses, and quality improvement department staff. This team also reviews significant adverse events that are not formally reported, such as unexpected deaths and hospitalizations. An initial review may be performed by a nurse practitioner or physician assistant on the team. With the aid of a form, reviewers indicate what they believe to be the primary source of the error, such as a provider problem or system error, and whether the error appears to be part of a systemic problem or trend. Reviewers can flag cases for committee discussion, quality improvement projects, and even divisional conferences. Some information may be forwarded to appropriate department heads as part of the peer review quality data for individual physician recredentialing.
  • Indepth evaluation of system problems: Systemic issues become the focus of a peer-review-protected quality improvement project involving all relevant providers and interested staff. Over time, case discussions have evolved from finger-pointing sessions to open dialogues about how systems of care can be improved. No case is closed until action is taken or systems developed to address and correct all issues. Some examples of reported problems and their resolution include:
    • Inconsistent followup for abnormal Pap tests: Review of this problem led to the development of a weekly direct feed of abnormal results into a departmental database, which was used to track individuals until the resolution of the abnormal result.
    • Failure to provide cardiac test results to providers ordering them: Test results were being given directly to supervising physicians, bypassing the midlevel providers who ordered them. Because the midlevel providers function quite independently, patients often did not receive timely and appropriate followup care. After identifying this problem, the review committee worked with the cardiac laboratory to ensure proper routing of results.
  • Feedback to the reporter: The individual who reported the case receives feedback at the completion of each case review, indicating the systems changes that resulted from the report. No specific feedback is given on individual errors or performance. Reporters are explicitly thanked for their contributions, even when the analysis reveals no error.
  • Ongoing evaluation and internal reporting to stimulate quality improvement: Quality improvement staff track a variety of HEDIS® (Healthcare Effectiveness Data and Information Set) measures, such as how often diabetic patients have their glycated hemoglobin measured, what percentage of diabetic patients have healthy glucose levels, and the like. These results are posted in the clinic's lobby to show staff and patients what improvements have been made. Trend data are reviewed monthly versus national benchmarks; when performance falls below the 90th percentile, the review committee meets to determine how the department, its systems, and its providers can improve.

Context of the Innovation

The Duke University Medical Center Department of Community and Family Medicine provides primary care to families covered by Medicare, Medicaid, and private insurers, and to Duke employees. The center's 10 full-time providers, including physicians and midlevel providers, handle roughly 40,000 patient visits per year; these staff are supported by nurses, pharmacists, social workers, dietitians, psychologists, and laboratory, radiology, and clerical staff. The center also trains family medicine residents and medical, physician assistant, and pharmacy students. Although North Carolina has no mandatory reporting law for primary care providers, Duke's hospital peer review system, which focuses on individual errors, had been reviewing medical errors at the outpatient clinic since the 1980s. In the mid-1990s, however, leaders decided to refocus peer review efforts on systems analysis and process improvements, leading to the development of the voluntary reporting system. In 2005, the system was further refined to incorporate general concerns and near-misses of all types; in addition, the system was revised to further emphasize the confidential nature of the error reporting process.

Did It Work?

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Results

The program has resulted in a sixfold increase in the number of errors reported and also appears to be associated with a decline in liability claims.
  • Increased reporting of errors: The number of error reports rose from 20 in 1997 to 120 in 2006 (a period of time during which the number of annual patient visits remained constant). In 2007, there were 105 cases reported. The 2006 data show that problems associated with laboratory reports and studies made up 41 percent of reported errors, with most mistakes being related to reporting and responding to results. Medication errors represented 10 percent of all reported errors. In 19 percent of cases, reviewers concluded that no error had occurred.
  • Fewer liability claims: The Department of Community and Family Medicine has experienced decreased liability claims since the program began. Although a direct causal link cannot be proven and multiple factors are certainly involved, department leaders believe that the improvements made as a result of this program were a contributing factor.

Evidence Rating (What is this?)

Suggestive: The evidence consists of pre- and post-implementation data on the number of error reports and liability claims, but there is no statistical evidence that confirms that the drop in liability claims resulted from the improvements inspired by the error reporting system. HEDIS® measures were not regularly tracked until after implementation of the error reporting system.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Changing the culture from reporting on each other to reporting themselves: Duke redefined its quality improvement programs and patient safety efforts to put the focus on systems analysis, process improvements, and betterment of care to move away from the punitive, finger-pointing culture of its prior reporting system. The reporting system was expanded to include problems and near-misses of all types. Because the Department of Community and Family Medicine is a teaching clinic, the quality improvement leader stressed that the new reporting system's style of asking questions when something did not go as planned was a natural expansion of the clinic's learning environment and would result in more self-reporting.
  • Getting administrative and clinician buy-in by promising closure on every report: The quality improvement champion and leader secured institutional backing for the voluntary error reporting initiative by promising that it would improve the quality of care at the center because every report would be reviewed and remain open until the related care process was improved and the report resolved.
  • Developing a simple tool for reporting: To make the reporting system easy to use, the quality improvement coordinator developed a single-page form that asked the reporter to identify the issue and actions taken, if any. Over time, additional questions were added, and as technology changed, reports were accepted in various formats to encourage the widest possible reporting. For example, a provider could send a brief, secure e-mail, or a copy of a patient complaint could be forwarded to the quality improvement coordinator.
  • Educating staff and physicians on program purpose: Duke quality improvement leaders constantly worked to familiarize staff with the reporting process to make sure they understood that systems improvement—not individual punishment—was the goal. The entire staff was involved as much as possible in problem-solving, and department-wide meetings were held to brainstorm around problematic issues to underscore that improvements and positive results occurred as a result of reporting.
  • Forming a confidential quality improvement team to review reports: A quality improvement committee, made up of representatives of the department, reviewed the error reports. Although the identity of the reporter was not confidential, once the report reached the committee, the committee's review and comments were kept highly confidential. Reviewers could identify which cases or issues should go before the full committee, become part of a quality improvement project, or be discussed in the peer-review-protected divisional Morbidity and Mortality conference if the problem was system-wide and had far-reaching ramifications on care processes.
  • Creating an error coding system: As the reporting system evolved, and more errors were reported as providers realized the investigations resulted in system improvements instead of scapegoating, the quality improvement coordinator created a taxonomy and system for categorizing the errors. This taxonomy has since spread to other medical units at Duke.
  • Resolving error reports: When a case is closed, it is cross-referenced in the peer review database, which includes links to any of the involved providers. This cross-reference is checked on an annual basis as part of the recredentialing process.

Resources Used and Skills Needed

  • Staffing: The medical director of each clinical unit dedicates up to 20 percent of his or her time to the program, while the department's quality improvement coordinator dedicates 20 percent of his or her time to the reporting system and the review of patient care metrics. Additional staff time is needed for coordination.
  • Costs: The program can cost up to $30,000 per year, with costs varying according to the size of the practice; roughly 1 percent of the clinical revenue of each unit is budgeted for quality improvement activities, and this program represents a portion of that cost.
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Funding Sources

Duke University Medical Center Department of Community and Family Medicine
The initiative is funded internally as part of the quality improvement program.end fs

Tools and Other Resources

The National Quality Measures Clearinghouse™, sponsored by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, is a public repository for evidence-based quality measures and measure sets. It includes information about many HEDIS measures and is available at: http://www.qualitymeasures.ahrq.gov.

Adoption Considerations

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Getting Started with This Innovation

  • Secure institutional support and dedicated staff time as needed.
  • Identify funding for quality improvement efforts—usually derived from clinical revenue.
  • Appoint a champion who is dedicated to quality improvement efforts.
  • Design a simple report form, and make submission as easy and discreet as possible.
  • Use a simple taxonomy to track types of issues identified, and focus efforts on those of highest frequency or highest risk.
  • Create peer review committees and processes that focus on system improvements.
  • Publicize the voluntary effort widely, promote self-reporting, and make clear this is not a punitive system.
  • Establish a feedback system so reporters are informed about what improvements were made.

Sustaining This Innovation

  • Constantly reinforce reporting: Quality improvement coordinators should constantly remind all members of the practice to report concerns and errors whenever the opportunity presents itself. Leaders must also model the reporting practice themselves whenever there is a concern or an unexpected occurrence in patient outcomes or care delivery. Reporters should be rewarded with thanks and provided information about changes made as a result of their contributions.
  • Look for ways to continuously improve systems: Error reporting systems in primary care have the potential to assist in ongoing practice redesign and the provision of meaningful feedback.
  • Work across systems: The biggest challenge for a hospital outpatient clinic is negotiating changes and systematic improvements that affect other departments that may not subscribe to the same error reporting and resolution protocol, or share the same goals. For example, the Duke Department of Community and Family Medicine has been working with outpatient laboratories to have certain test results highlighted at the top of results reports, and to have abnormal results from tests performed in the inpatient setting transferred to the outpatient clinic after the patients are discharged.

Use By Other Organizations

The Department of Community and Family Medicine in Durham has had two inquiries from programs outside of Duke. They have also had other departments/divisions within Duke ask about the program. The system has been used by other divisions within the Duke Department of Community and Family Medicine.

Additional Considerations

  • The number of error reports per provider depends on patient volume and whether the provider self-reports unexpected outcomes. High-volume providers naturally receive more error reports, and the system recognizes this and does not punish high-volume providers due to the higher number of error reports.
  • During the past year, the Department of Community and Family Medicine confirmed their practice and belief that any volunteer program requires regular encouragement to report as well as updates to those that participate. This is best manifested in providing direct feedback to individuals who report concerns. Participants appreciate knowing that their efforts to report concerns lead to meaningful change.

More Information

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Contact the Innovator

Devdutta Sangvai, MD, MBA
Vice Chair for Quality & Safety
Department of Community and Family Medicine
Duke University
Box 3886 DUMC
Durham, NC 27710
Phone: (919) 684-5502
E-mail: devdutta.sangvai@duke.edu

Innovator Disclosures

Dr. Sangvai reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

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(11):927-32. [PubMed]

Fischer G, Fetters MD, Munro AP, et al. Adverse events in primary care identified from a risk-management database. J Fam Pract. 1997;45(1):40-6. [PubMed]

Elder NC, Graham D, Brandt E, et al. Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN). J Am Board Fam Med. 2007;20(2):115-23. [PubMed] Available at: http://www.jabfm.org/content/20/2/115.abstract.

Plews-Ogan ML, Nadkarni MM, Forren S, et al. Patient safety in the ambulatory setting. A clinician-based approach. J Gen Intern Med. 2004;19(7):719-25. [PubMed]

Kaprielian VS, Østbye T, Warburton S, et al. A System to Describe and Reduce Medical Errors in Primary Care. Washington, DC: Agency for Healthcare Research and Quality, 2008. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1
/Advances-Kaprielian_9.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality, 2008.

Footnotes

1 Elder NC, Vonder Meulen M, Cassedy A. The identification of medical errors by family physicians during outpatient visits. Ann Fam Med. 2004;2(2):125-9. [PubMed] Available at: http://www.annfammed.org/cgi/content/full/2/2/125.
2 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(11):927-32. [PubMed]
3 Fischer G, Fetters MD, Munro AP, et al. Adverse events in primary care identified from a risk-management database. J Fam Pract. 1997;45(1):40-6. [PubMed]
4 Elder NC, Graham D, Brandt E, et al. Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN). J Am Board Fam Med. 2007;20(2):115-23. [PubMed] Available at: http://www.jabfm.org/cgi/content/abstract/20/2/115.
5 Plews-Ogan ML, Nadkarni MM, Forren S, et al. Patient safety in the ambulatory setting. A clinician-based approach. J Gen Intern Med. 2004;19(7):719-25. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 04, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 01, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.