Counter to the prevailing perception that adverse drug events and surgical mishaps are the primary causes of medical errors, this qualitative study of 38 patients suggests that breakdowns in the clinician-patient relationship (37 percent) and access to clinicians (29 percent) may be more prominent. When asked about problems they experienced in the primary care office setting, patients were more likely to report being harmed psychologically and emotionally (70 percent) than physically (23 percent), suggesting that the current preoccupation of the patient safety movement could overlook other patient priorities. The authors posit that although systems changes might ameliorate some of the errors patients report, they do not directly address the rushed, dehumanizing health care experiences identified by the patients who participated in this study.
Patient Reports of Preventable Problems and Harms in Primary Health Care
By Anton J. Kuzel, M.D., M.H.P.E., et al
Studying Medical Errors as a String of Mistakes Sheds Light on Root Cause, Often Miscommunication
While much of the patient safety movement has focused on the medical errors that are easiest to recognize and remedy, including adverse drug events and surgical mishaps, many diagnostic and treatment errors may actually begin with errors in communication. By studying medical errors as a chain of events, Woolf and colleagues find that two out of every three mistakes in treatment and diagnosis were set into motion by errors in communication. In a study of error reports from 18 primary care offices in six different countries, the researchers found that a chain of errors occurred in 77 percent of the reported incidents. Fully 80 percent of those errors involved personal or informational miscommunication. Examples of informational miscommunication included communication breakdowns among colleagues and with patients (44 percent), misinformation in the medical record (21 percent), mishandling of patients' requests and messages (18 percent), inaccessible medical records (12 percent), and inadequate reminder systems (5 percent). The authors suggest that safety initiatives should focus less on professional interventions to improve clinical judgment and more on management systems to enhance the quality of information transfer.
A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors
By Steven H. Woolf, M.D., M.P.H., et al
Women and Physicians Wary of Advance Prescriptions to the Morning-After Pill
Does it encourage irresponsible sex?
Even though the morning-after pill has been available in the United States for many years, it remains underprescribed and underused, in part because the prescribing model typically used by physicians – emergency prescribing – requires that a patient know about and request the drug after an act of unprotected intercourse. Given the recent FDA decision to reject over-the-counter sale of morning-after contraception, many are considering the benefits of an advance prescription model, by which physicians routinely counsel patients and offer them advance prescriptions or an emergency contraception packet during an office visit. However, the results of a qualitative study of 38 patients and 25 physicians in an inner-city family medicine clinic indicate that while both women and physicians have favorable attitudes toward emergency contraception, many have serious reservations about physicians providing patients with advance prescriptions for the drug. Although of the women who participated in the study felt advance prescriptions would increase the likelihood of their taking emergency contraception after unprotected sex, a few had reservations about habitual or repeated use and expressed concern that it might increase sexual risk taking. Forty percent of the physicians interviewed also had serious reservations about advance prescriptions, expressing concern that making emergency contraception more accessible to patients would increase rates of unprotected intercourse. Both physicians and patients felt that physicians should take a proactive role in educating patients about the method; however, only about one fourth of physicians said they prescribed emergency contraception often, and few routinely talked with their patients about it. The authors point out that while advance prescription has been shown to increase use of emergency contraception after unprotected sex, it does not increase frequency of unprotected intercourse. They suggest that sharing this information with patients and physicians might facilitate prescribing and use.
The Visit Before the Morning After: Barriers to Preprescribing Emergency Contraception
By Alison Karasz, Ph.D., et al
Unnecessary Lyme Disease Tests Put a Drain on Health Care System
Each year, approximately 2.8 million tests are done in the United States to detect Lyme disease at a cost of more than $100 million to the health care system. However, according to a study by Ramsey and colleagues, many of these tests are ordered inappropriately, often as a result of patient demand. Of the 356 Lyme disease serologic tests sampled, only 20 percent were subsequently classified as appropriate, and at least 27 percent were inappropriate. The authors point out that nearly 40 percent of the tests requested by patients were inappropriate, and in more than half of the inappropriate tests, the patient did not show symptoms of the disease. They authors assert that inappropriate Lyme disease testing represents an inefficient use of health care resources and may contribute to both under- and over-diagnosis, and result in unnecessary antibiotic treatment. They recommend expanded education for clinicians and patients focusing on the indications for Lyme disease testing, particularly that the absence of symptoms with or without a known or suspected recent tick bite obviates the need for testing.
Use and Appropriateness of Lyme Disease Serologic Testing
By Alan H. Ramsey, M.D., M.P.H.&T.M., et al
Simple, Low-Cost Intervention Shown to Improve Cancer Screening Among Underserved Patients
A simple, low-cost office system intervention shows great promise as a way to increase cancer screening among disadvantaged patients. The program, Cancer Screening Office Systems, consists of a cancer-screening checklist; colored chart stickers to indicate whether tests are due, have been ordered or have been completed; and a division of responsibilities among office staff. In a randomized controlled trial involving eight primary care clinics, the intervention more than doubled the odds of fecal occult blood test screening, increased the odds of mammograms more than 60 percent and increased the odds of screening pap smears more than 50 percent. As the authors point out, statistics show that disadvantaged patients, including racial and ethnic minorities, patients of low socioeconomic status and those who are uninsured or insured by Medicaid are more likely to have poor cancer outcomes, possibly in part to lower use of screening tests. While other successful interventions to increase cancer screening have relied on technology, personnel and resources that may not be widely available to clinics caring for the underserved, this intervention's novelty stems from the fact that it is inexpensive, noncomputerized, involves the patient in the screening process, and relies on personnel and resources that are available in most primary care clinics.
A Randomized Controlled Trial to Increase Cancer Screening Among Attendees of Community Health Centers
By Richard C. Roetzheim, M.D., M.S.P.H., et al
Patients Want to Discuss Spirituality with Their Physicians
In a survey of 921 adult patients, most (83 percent) wanted their physicians to ask them about their spiritual beliefs in at least certain instances. The researcher found the percentage of those welcoming spiritual discussion increased with the severity of illness. Discussion of spirituality is most welcome in cases of a life-threatening illness (77 percent), a serious medical condition (74 percent) or following the death of a loved one (70 percent). Among those who wanted to discuss spirituality, the most important reason for discussion was the desire for physician-patient understanding (87 percent).
Discussing Spirituality with Patients: A Rational and Ethical Approach
By Gary McCord, M.A.
OTHER STUDIES IN THIS ISSUE:
Preventing Errors in Clinical Practice: A Call for Self-Awareness
By Francesco Borrell-Carrió, M.D., et al
Providing a complement to the patient safety movement's current focus on systems improvement, Borrell-Carrió and colleagues propose a new rational-emotive model focused on helping doctors develop their insight and self-awareness as a way to reduce medical errors. The model focuses on helping physicians become aware of their early hypotheses and how they frame the clinical encounter. It emphasizes two factors: 1) the importance for clinicians to reframe their original hypothesis and 2) the need for clinicians to learn cognitive and emotional strategies that might help them manage difficult or tense patient encounters so those encounters are not ended precipitously.
Screening for Syphilis Infection: Recommendation Statement
By the U.S. Preventive Services Task Force
Updating its 1996 recommendation, the U.S. Preventive Services Task Force issued a statement strongly recommending that pregnant women and people who are at higher risk for syphilis infection receive screening tests for the disease. The Task Force recommends against routine screening of people who are not at increased risk for syphilis infection and do not show symptoms of the disease.
Going to Scale: Re-Engineering Systems for Primary Care Treatment of Depression
By Allen J. Dietrich, M.D., et al
Dietrich and colleagues from the MacArthur Foundation Initiative on Depression and Primary Care report on the RESPECT-Depression project, which includes a randomized controlled trial to test a new evidence-based clinical model for treating depression. The model is currently being implemented and evaluated by 180 clinicians in 60 medical practices nationwide. The new system enhances care by providing a system for depression management as recommended by the U.S. Preventive Services Task Force. As part of the report, Dietrich and colleagues also describe a practice change strategy and the methods for evaluating the model's impact.
Primary Care Providers Evaluate Integrated and Referral Models of Behavioral Health Care for Older Adults: Results from a Multisite Effectiveness Trial (PRISM-E)
By Joseph J. Gallo, M.D., M.P.H., et al
When treating older adults for depression and other mental health conditions, most primary care physicians prefer an integrated approach to care in which the mental health specialist is located in the same office as the patient's primary care doctor rather than enhanced referral care in which the patient is referred to a separate mental health clinic. Physicians feel the integrated approach leads to better communication between doctors and mental health specialists (93 percent), less stigma for patients (93 percent), and better coordination of mental and physical care (92 percent).
Event Reporting to a Primary Care Patient Safety Reporting System: A Report from the ASIPS Collaborative
By Douglas H. Fernald, M.A., et al
Analyzing 608 error reports to the Applied Strategies for Improving Patient Safety demonstration project, Fernald and colleagues found that communications problems (71 percent), diagnostic tests (47 percent), medication problems (35 percent), and both diagnostic test and medications (14 percent) were among the errors most frequently reported by clinicians. When comparing the two types of reports clinicians could use to report errors – confidential (requiring the reporter's name and phone number) and anonymous – the researchers found that the confidential reports' greater detail added to their ability to understand errors and design interventions to decrease them.
Subclinical Hypothyroidism and the Risk of Hypercholesterolemia
By William J. Hueston, M.D., et al
While hypothyroidism is associated with abnormalities in cholesterol, a study of 8,228 patients finds that subclinical hypothyroidism does not lead to increased levels of cholesterol or triglycerides. Based on these results, the authors conclude that screening for subclinical hypothyroidism simply to identify lipid abnormalities would be no more useful than screening for hyperlipidemia in general.
Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians, the American Board of Family Practice, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the North American Primary Care Research Group. The journal is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.
Journal
The Annals of Family Medicine