BACKGROUND We wanted to describe errors and preventable adverse events identifi ed by family physicians during the offi ce-based clinical encounter and to determine the physicians' perception of patient harm resulting from these events. METHODWe sampled Cincinnati area family physicians representing different practice locations and demographics. After each clinical encounter, physicians completed a form identifying process errors and preventable adverse events. Brief interviews were held with physicians to ascertain their perceptions of harm or potential harm to the patient. RESULTSFifteen physicians in 7 practices completed forms for 351 outpatient visits. Errors and preventable adverse events were identifi ed in 24% of these visits. There was wide variation in how often individual physicians identifi ed errors (3% to 60% of visits). Offi ce administration errors were most frequently noted. Harm was believe to have occurred as a result of 24% of the errors, and was a potential in another 70%. Although most harm was believed to be minor, there was disagreement as to whether to include emotional discomfort and wasted time as patient harm.CONCLUSIONS Family physicians identify errors and preventable adverse events frequently during patient visits, but there is variation in how some error categories are interpreted and how harm is defi ned. INTRODUCTIONT he role of medical errors and adverse events as important factors in the health outcomes of patients is well known, at least for hospitalized patients.1,2 Identifying adverse events and attributing cause to error, however, is diffi cult.3-5 Most of the medical care in the United States occurs not in the hospital but in the outpatient primary care setting, 6 where the role of medical errors is even less clear. Until now outpatient studies have collected retrospective physician-generated reports of errors they have made 7 or noted in their practices. [8][9][10] A few studies have examined specifi c areas of potential error, such as physician-patient communication, 11 specialist-primary care communication, 12 or incident report claims. 13 When combined, these studies begin to document the full breadth of errors recognized primarily by physicians, but they offer minimal information on incidence or severity.14 A more accurate assessment of the incidence and severity of errors and preventable adverse events in primary care is necessary to develop successful interventions to improve patient safety.The purpose of this study was to have physicians identify prospectively those errors and preventable adverse events that occur during offi ce-based clinical encounters and to assess the physicians' perceptions of harm from these errors. This effort is a preliminary step in defi ning the incidence of medical errors and their associated harm in outpatient primary care. METHODS SampleTwo to 4 physicians in each of 9 family practice offi ces in the greater Cincinnati area were approached to take part in a study "of the errors and problems that seem to occur almost daily in...
Background: A single self-rated health (SRH) question is associated with health outcomes, but agreement between SRH and physician-rated patient health (PRPH) has been poorly studied. We studied patient and physician reasoning for health ratings and the role played by patient lifestyle and objective health measures in the congruence between SRH and PRPH.Methods: Surveys of established family medicine patients and their physicians, and medical record review at 4 offices. Patients and physicians rated patient health on a 5-point scale and gave reasons for the rating and suggestions for improving health. Patients' and physicians' reasons for ratings and improvement suggestions were coded into taxonomies developed from the data. Bivariate relationships between the variables and the difference between SRH and PRPH were examined and all single predictors of the difference were entered into a multivariable regression model.Results: Surveys were completed by 506 patients and 33 physicians. SRH and PRPH ratings matched exactly for 38% of the patient-physician dyads. Variables associated with SRH being lower than PRPH were higher patient body mass index (P ؍ .01), seeing the physician previously (P ؍ .04), older age, (P < .001), and a higher comorbidity score (P ؍ .001). Only 25.7% of the dyad reasons for health status rating and 24.1% of needed improvements matched, and these matches were unrelated to SRH/PRPH agreement. Physicians focused on disease in their reasoning for most patients, whereas patients with excellent or very good SRH focused on feeling well. Conclusions
Background Smoking is the leading preventable cause of morbidity and mortality in the United States, killing more than 450,000 Americans. Primary care physicians (PCPs) have a unique opportunity to discuss smoking cessation evidence in a way that enhances patient-initiated change and quit attempts. Patients today are better equipped with technology such as mobile devices than ever before. Objective The aim of this study was to evaluate the challenges in developing a tablet-based, evidence-based smoking cessation app to optimize interaction for shared decision making between PCPs and their patients who smoke. Methods A group of interprofessional experts developed content and a graphical user interface for the decision aid and reviewed these with several focus groups to determine acceptability and usability in a small population. Results Using a storyboard methodology and subject matter experts, a mobile app, e-Quit worRx, was developed through an iterative process. This iterative process helped finalize the content and ergonomics of the app and provided valuable feedback from both patients and provider teams. Once the app was made available, other technical and programmatic challenges arose. Conclusions Subject matter experts, although generally amenable to one another’s disciplines, are often challenged with effective interactions, including language, scope, clinical understanding, technology awareness, and expectations. The successful development of this app and its evaluation in a clinical setting highlighted those challenges and reinforced the need for effective communications and team building.
Background: Smoking is the leading preventable cause of morbidity and mortality in the United States.Primary care providers (PCPs) have a unique opportunity to engage patients to quit smoking, but to be effective, clinicians must be able to personalize evidence-based interventions that are useful and appealing to patients in a time efficient manner. We pilot tested a novel iPad application (app), called e-Quit worRx™, designed to enhance patient-centered shared-decision making (SDM) about smoking cessation, with the primary goal of determining feasibility in primary care offices.Methods: A total of 73 patients from three offices within a local diverse primary care network were enrolled in a pragmatic single crossover-controlled trial. The decision aid app was incorporated into current smokers' waiting time for their PCP in the exam room, and their PCP reviewed their personal responses and selections to finalize treatment choices. Mixed methods were used in the evaluation and the primary outcomes were app feasibility in primary care and enhanced SDM.Results: Our app was determined to be feasible for use in primary care for both patients and PCPs. It significantly increased time spent discussing smoking cessation with their PCP and the likelihood that a decision was made at the time of the visit. While not significant, mean differences were observed in other study measures including SDM, decisional conflict, quality of patient-provider communication, and stage of change progression at 12 weeks post-trial. Conclusions:We created a usable and acceptable iPad app-based decision aid for use in primary care offices. The design process presented several challenges including integration into a clinical setting. Despite these challenges, we successfully ran a pragmatic pilot trial in three primary care offices using a technology novel to many of the users.
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