Toward a theoretical approach to medical error reporting system research and design

Karsh, Ben‐Tzion; Escoto, Kamisha Hamilton; Beasley, John W.; Holden, Richard J.

doi:10.1016/j.apergo.2005.07.003

Cited by 80 publications

(81 citation statements)

References 32 publications

(38 reference statements)

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“…For example, collaborations can facilitate exploration of the needs and perceptions of patients, the ways they access and use health care services, 26,27 and issues in patient safety. 67 The primary care research environment is enriched by researchers who have a wide range of professional skills and who are motivated and able to work with primary care researchers. At the same time, these academic researchers must understand the need to collaborate with community clinicians who can help articulate the important questions and apply the answers to practice.…”

Section: (2) Collaborations With Other Disciplinesmentioning

confidence: 99%

Global Health and Primary Care Research

Beasley¹,

Starfield²,

Weel³

et al. 2007

The Journal of the American Board of Family Medicine

100

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A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in primary care is essential to inform practice and to develop better health systems and health policies. Among the challenges for primary care, especially in countries with limited resources, is the need to enhance the research capacity and to engage primary care clinicians in the research enterprise. These caregivers need to be an integral part of the research enterprise so the right questions will be asked, the results from research will be used in practice, and a scholarly and evidence-based approach to primary care will become the norm.The challenge of developing research in primary care can be met only by creating a strong infrastructure. This will include strengthening academic departments, enhancing links to researchers in other fields, improving training programs for future primary care researchers, developing more practicebased primary care research networks, and increasing funding for research in primary care. A greatly increased commitment on the part of international organizations both within and outside of primary care is needed, in particular those organizations involved with funding research. We provide suggestions to improve the global primary care research enterprise for the benefit of the world's population. A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and in resource-poor countries. To improve equity in health it is vitally important to improve health services for the world's poorest and least healthy people.1 Among the challenges for developing a strong primary care system, especially in countries with limited resources, is that of developing research capacity in primary care. This capacity is needed to inform practice and to improve health systems and policies. This paper reviews the evidence supporting the role of the primary care system in providing effective and efficient health care, the need for primary care research to be part of this system, a description of the primary care research, and recommendations to strengthen the primary care research enterprise. The Strength of Primary Care Predicts a Population's Health StatusStudies of the value of health services have concluded that approximately half of the improvements in the health of populations in the past half century are attributable to health services, with other factors (geography, nutrition, public health measures) accounting for the remainder.2-4 Within the last 2 decades, several researchers have shown that the strength of the primary care component of health systems is positively related to most common indicators of population health status, including birth outcomes, potential years of life lost, ageadjusted death rates, and age-specific mortality rates. The benef...

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Section: (2) Collaborations With Other Disciplinesmentioning

confidence: 99%

Global Health and Primary Care Research

Beasley¹,

Starfield²,

Weel³

et al. 2007

The Journal of the American Board of Family Medicine

100

View full text Add to dashboard Cite

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“…9,11,12,14 In addition, a belief that reporting will make no difference has also been cited as a reason for underreporting. 10,11,14 Less is known about what encourages health care personnel to make reports. 9,11,14 With the passage of the Patient Safety and Quality Improvement Act of 2005, 15 it is likely that error and event reporting will spread from hospi-tals, where it is common, to ambulatory care settings, where it rarely occurs and is not part of routine work.…”

mentioning

confidence: 99%

“…10,11,14 Less is known about what encourages health care personnel to make reports. 9,11,14 With the passage of the Patient Safety and Quality Improvement Act of 2005, 15 it is likely that error and event reporting will spread from hospi-tals, where it is common, to ambulatory care settings, where it rarely occurs and is not part of routine work. As with most patient safety research, the majority of work on error reporting has been performed in a hospital setting.…”

mentioning

confidence: 99%

“…1,5 Many reasons have been proposed for this underreporting, including underrecognition, 6,7 confusion about definitions, [7][8][9][10] fear of blame and punishment, 9 -12 concerns about anonymity and confidentiality, 9,11,13 and the amount of time and effort required to report. 9,11,12,14 In addition, a belief that reporting will make no difference has also been cited as a reason for underreporting. 10,11,14 Less is known about what encourages health care personnel to make reports.…”

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confidence: 99%

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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)

Elder¹,

Graham²,

Brandt³

et al. 2007

The Journal of the American Board of Family Medicine

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Context:Reporting of medical errors is a widely recognized mechanism for initiating patient safety improvement, yet we know little about the feasibility of error reporting in physician offices, where the majority of medical care in the United States is rendered.Objective: To identify barriers and motivators for error reporting by family physicians and their office staff based on the experiences of those participating in a testing process error reporting study.Design: Qualitative focus group study, analyzed using the editing method. Setting: Eight volunteer practices of the American Academy of Family Physicians National Research Network.Participants: 139 physicians, nurse practitioners, physician assistants, nurses, and staff who took part in 18 focus groups.Instrument: Interview questions asked about making reports, what prevents more reports from being made, and decisions about when to make reports.Results: Four factors were seen as central to making error reports: the burden of effort to report, clarity regarding the information requested in an error report, the perceived benefit to the reporter, and properties of the error (eg, severity, responsibility). The most commonly mentioned barriers were related to the high burden of effort to report and lack of clarity regarding the requested information. The most commonly mentioned motivator was perceived benefit.Conclusion: Successful error reporting systems for physicians' offices will need to have low reporting burden, have great clarity regarding the information requested, provide direct benefit through feedback useful to reporters, and take into account error severity and personal responsibility.

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“…However, in low income countries endorsing a new or improved health technology in itself does not guarantee enduser utilization [3]. Other studies conducted in developed nations reported several factors responsible for acceptance and use of new health technologies [4,5]. These factors include organizational features such as how well the new technology is integrated with existing technologies, workflow, and top management commitment to the new technology.…”

Section: Introductionmentioning

confidence: 99%

Health Care Worker’s Experience on Rapid Diagnostic Test (Rdt) for Malaria and Their Views on Community Acceptability of Rdt in Rubavu District, Rwanda: Qualitative Study

Misbah¹

2017

Malaria Contr Elimination

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Background: Malaria remains one of the major public health problems in Rwanda. The country introduced artemisinin combination therapy (ACT) at community level using community health workers (CHWs) for treatment of uncomplicated malaria in 2008. Use of ACT with reliance on presumptive diagnosis may lead to excessive use, increased costs and rise of drug resistance. Thus to overcome these challenges, rapid diagnostic tests (RDTs) was introduced to be done by CHWs. This study assessed health care workers experience regarding RDT and their feelings on acceptability of RDTs by community members.

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Toward a theoretical approach to medical error reporting system research and design

Cited by 80 publications

References 32 publications

Global Health and Primary Care Research

Global Health and Primary Care Research

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)

Health Care Worker’s Experience on Rapid Diagnostic Test (Rdt) for Malaria and Their Views on Community Acceptability of Rdt in Rubavu District, Rwanda: Qualitative Study

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