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Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network

¹ American Academy of Family Physicians, National Research Network, Leawood, Kansas, USA
² CNA Corporation, Alexandria, Virginia, USA
³ Department of Family Medicine, University of Cincinnati, Cincinnati, Ohio, USA
⁴ Department of Family Medicine, University of Colorado at Denver and Health Sciences Center, Aurora, Colorado, USA
⁵ Department of Family Medicine, University of Chicago, Chicago, Illinois, USA

Correspondence to:
D Graham, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211, USA; dgraham{at}aafp.org

ABSTRACT
Objectives: Little research has focused on preventing harm from errors that occur in primary care. We studied mitigation of patient harm by analysing error reports from family physicians’ offices.

Methods: The data for this analysis come from reports of testing process errors identified by family physicians and their office staff in eight practices in the American Academy of Family Physicians National Research Network. We determined how often reported error events were mitigated, described factors related to mitigation and assessed the effect of mitigation on the outcome of error events.

Results: We identified mitigation in 123 (21%) of 597 testing process event reports. Of the identified mitigators, 79% were persons from inside the practice, and 7% were patients or patient’s family. Older age was the only patient demographic attribute associated with increased likelihood of mitigation occurring (unadjusted OR 18–44 years compared with 65 years of age or older = 0.27; p = 0.007). Events that included testing implementation errors (11% of the events) had lower odds of mitigation (unadjusted OR = 0.40; p = 0.001), and events containing reporting errors (26% of the events) had higher odds of mitigation (unadjusted OR = 1.63; p = 0.021). As the number of errors reported in an event increased, the odds of that event being mitigated decreased (unadjusted OR = 0.58; p = 0.001). Multivariate logistic regression showed that an event had higher odds of being mitigated if it included an ordering error or if the patient was 65 years of age or older, and lower odds of being mitigated if the patient was between age 18 and 44, or if the event included an implementation error or involved more than one error. Mitigated events had lower odds of patient harm (unadjusted OR = 0.16; p<0.0001) and negative consequences (unadjusted OR = 0.28; p<0.0001). Mitigated events resulted in less severe and fewer detrimental outcomes compared with non-mitigated events.

Conclusion: Nearly a quarter of testing process errors reported by family physicians and their staff had evidence of mitigation, and mitigated errors resulted in less frequent and less serious harm to patients. Vigilance throughout the testing process is likely to detect and correct errors, thereby preventing or reducing harm.