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Quality and Safety


Quality & Safety Issues in Primary Care Practice

Vaccine safety

  1. Adverse events from vaccine delivery process: giving wrong vaccine, administration at wrong time in schedule, unnecessary/duplicate vaccination, administration via wrong route, prescribing error/wrong dose (t)

  2. Storage errors resulting in loss of vaccines

Resources to reduce vaccine errors: linked, up-to-date immunization records, reporting standards for adverse events/errors/near-miss (u,v)

Medication Errors

  1. Prescribing errors – wrong medication, drug-drug interactions, transcription errors

  2. Filling errors – not filling medications, knowledge gap of purpose of medication, not taking as prescribed

  3. Administration errors – wrong medication, wrong patient, wrong dosage, medication administration outside scope

Resourcesto reduce medication errors: Thorough medication reconciliation, up to date patient medication lists, team based care integrating clinical pharmacist in primary care practice to reduce medication errors, computerized order entry, barcode medication administration systems (f,g,h,I,j)

Polypharmacy

  1. Medication errors more common among individuals with polypharmacy (w)

  2. Polypharmacy increases risk of hospitalization, drug interactions & adverse drug reactions (x)

Communication breakdowns

  1. Communication lapses have potential to lead to medical error, near miss, unsafe conditions.

  2. Often involved in medication, diagnostic & treatment errors

  3. Breakdown in communication between primary care & other settings can lead to duplication, missed or inappropriate care

Resources to improve communication breakdowns: education of patient & provider team, Team STEPPS, SBAR, daily practice huddles (k,l,m, n)

Laboratory and Test Follow up

  1. Poor test result follow-up can result in missed diagnoses & poor patient outcomes(bb)

  2. Some studies have shown 11% of serious clinical incident (serious harm, death), and 32% of clinical incidents with major patient consequences can be attributed to inadequate test follow up (bb)

    1. Missed results – pending at discharge, missed culture result requiring initial treatment change

    2. Delayed results – resulting in treatment delay or diagnosis

Inequity in care delivery

EHR errors

  1. Healthcare information technology has been touted to be a method of improving delivery of safe health care, particularly when applied to prescribing & medication safety. However, research has indicated that poorly designed or inappropriately implemented electronic healthcare records and applications can contribute to medical error (y,z)

  2. Areas of EHR safety concern can include:

  3. Mismatch between information needs and content display – order entry on wrong patient due to multiple screens being open, need to review multiple screens to determine active orders or medications

  4. Software modifications or configuration changes – may allow unauthorized users access to order entry,

  5. System interface errors – duplicate EHR records for one patient resulting in inappropriate order entry

Resources – importance of no blame reporting for errors which occur as a result of EHR provider-computer interface, software-software interface or system interface. Diagnostic Errors

  1. Estimated 1/20 adult patients affected by diagnostic error (o)

  2. Diagnostic errors typically involve communication or process breakdown (p)

  3. Integration of patient, family & provider team can reduce diagnostic error (p, q)

Resources: shared decision making practice models, pre-visit planning, use of EMR to facilitate timely communication, use of technology resources to improve adherence & understanding of plan of care (r,s) QSEN Competencies useful for practice improvement of Vaccine Safety, Medication Errors, Polypharmacy, Communication Breakdowns, Test Result Follow up, HER Errors & Diagnostic Errors

  1. Patient Centered Care

    1. Knowledge

      1. Discuss principles of effective communication

      2. Describe principles of consensus building and conflict resolution

  • Examine how the safety, quality & cost effectiveness of health care can be improved through involvement of patients/families

  1. Equity issues-culture-language


  1. Skills:

    1. Communicate care provided & needed at each transition in care

  2. Attitude

    1. Value the patient’s expertise with own health and symptoms

    2. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care

  3. Teamwork & Collaboration

    1. Knowledge

      1. Describe strategies for ID & managing overlaps in team member roles & accountabilities

      2. Analyze differences in communication style preferences & impact on others

  • Discuss effective strategies for communicating & resolving conflict

  1. ID system barriers for effective team function


  1. Skills

    1. Participate in designing system that support team work

    2. Follow communication practices that minimize risks associate with handoffs among providers & across transitions in care

  2. Attitudes

    1. Appreciate risk associated with handoff & transitions in care

  3. Evidence Based Practice

    1. Knowledge

      1. Explain the role of evidence in determining best clinical practice

      2. Describe reliable sources for locating evidence reports & clinical practice guidelines

    2. Skills

      1. Locate evidence reports related to clinical practice topics & guidelines

      2. Question rational for routine approaches to care that result in less-than desired outcomes or adverse events

    3. Attitudes

      1. Value the need for continuous improvement

      2. Appreciate the risks associated with handoffs among providers and across transitions in care

  4. Safety:

    1. Knowledge

      1. Examine human factors & basic safety design, common unsafe practices

      2. Evaluated safety enhancing technology (barcodes, CPOE)

  • Describe how root cause analysis can help us understand when safety event or error occurs

  1. Skills

    1. Use of technology & standardized practices that support safety & quality

    2. Strategies to reduce reliance on memory

  • Participate in appropriately analyzing errors & design system improvements

  1. Engage in RCA when error/near miss occurs


  1. Attitudes

    1. Appreciate the cognitive and physical limits of human performance

    2. Value own role in preventing errors

  2. Informatics

    1. Knowledge

      1. Describe examples of how technology & information management are related to quality & safety

    2. Skills

      1. Apply technology & information management tools to support safe processes of care

    3. Attitudes

      1. Appreciate the necessity for all health professionals to seek lifelong, continuous learning of information technology skills

      2. Value technologies that support clinical decision-making, error prevention, and care coordination

  • Value nurses’ involvement in design, selection, implementation, and evaluation of information technologies to support patient care


6. Quality Improvements

  1. Knowledge

    1. Importance of variation & measurement in assessing quality of care

    2. Described approaches for changing processes of care

  2. Skills

    1. Use quality measures to understand performance

    2. Identify gaps between local & best practice

  • P-D-S-A to test change in daily work

  1. Use tools helpful for understanding variation


  1. Attitude

    1. Appreciate that continuous quality improvement is an essential part of the daily work of all health professionals

    2. Appreciate the value of what individuals and teams can to do to improve care


Resource/Reference:


2017. Smith K, Baker K, Wesley D, et al. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families: Environmental Scan Report. (Prepared by: MedStar Health Research Institute under Contract No. HHSP233201500022I/HHSP23337002T.) Rockville, MD: Agency for Healthcare Research and Quality; February 2017. AHRQ Publication No. 17-0021-2-EF. https://www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/envscan.html

2010. Scholle S, Torda P, Peikes D, et al. Engaging patients and families in the medical home. Rockville, MD: Agency for Healthcare Research and Quality; June 2010. AHRQ Publication No. 10-0083-EF. http://pcmh.ahrq.gov/sites/default/files/attachments/Engaging Patients and Families in the Medical Home.pdf

93. Hernan AL, Giles SJ, Fuller J, et al. Patient and carer identified factors which contribute to safety incidents in primary care: a qualitative study. BMJ Qual Saf 2015;24:583-93. http://qualitysafety.bmj.com/content/24/9/583.abstract


110. Bell BG, Spencer R, Avery AJ, et al. Tools for measuring patient safety in primary care settings using the RAND/UCLA appropriateness method. BMC Fam Pract 2014;15:110. doi:10.1186/1471-2296-15-110

41. Baker R, Willars J, McNicol S, et al. Primary care quality and safety systems in the English National Health Service: a case study of a new type of primary care provider. J Health Serv Res Policy 2013;19(1):34-41. DOI:1177/1355819613500664.

2005. Agency for Healthcare Research and Quality. Patient Education and Staff Training Significantly Improves Medication Reconciliation in Outpatient Clinics. 2005. https://innovations.ahrq.gov/profiles/patient-education-and-staff-training-significantly-improves-medication-reconciliation.

41. Nemeth LS, Wessell AM. Improving medication safety in primary care using electronic health records. J Patient Saf 2010;6(4):238-43. PMID:21500611

2004. Agency for Healthcare Research and Quality. Reconciliation of Patient and Provider Medication Lists Reduces Discrepancies and Enhances Medication Safety in Physician Clinics. 2004. https://innovations.ahrq.gov/profiles/reconciliation-patient-and-provider-medication-lists-reduces-discrepancies-and-enhances.

1. org. General Advice on Safe Medication Use. http://www.consumermedsafety.org/tools-and-resources/medication-safety-tools-and-resources/taking-your-medicine-safely/general-advice-on-safe-medication-use

2008. Pathways for Patient Safety: Module Three: Creating Medication Safety. Chicago, IL: Health Research & Educational Trust; 2008. http://www.hret.org/quality/projects/resources/creating_medication_safety.pdf.

2011. Agency for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. 2011. https://archive.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html

9. Freitag M, Carroll VS. Handoff communication: using failure modes and effects analysis to improve the transition in care process. Qual Manag Health Care 2011;20(2):103-9. doi:10.1097/QMH.0b013e3182136f58

32. Stead K, Kumar S, Schultz TJ, et al. Teams communicating through STEPPS. Med J Aust 2009;190(11 Suppl):S128-32. http://www.ncbi.nlm.nih.gov/pubmed/19485861.

92. Weaver R. Seeking high reliability in primary care: leadership, tools, and organization. Health Care Manage Rev 2015;40(3):183-92. http://www.ncbi.nlm.nih.gov/pubmed/24787749

31. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving U.S. adult populations. BMJ Qual Saf 2014;23(9):727-31. doi:10.1136/bmjqs-2013-002627.

25. Singh H, Giardina TD, Meyer AN, et al. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med 2013;173(6):418-25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690001

9. McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient safety strategies targeted at diagnostic errors: a systematic review. Ann Intern Med 2013;158(5 Pt 2):381-9.

1. Jenssen PB, Mitra N, Shah A, et al. Using digital technology to engage and communicate with patients: a survey of patient attitudes. J Gen Intern Med 2015;31(1):85-92

2. Agency for Healthcare Research and Quality. The SHARE Approach: Essential Steps of Shared Decision Making: Expanded Reference Guide With Sample Conversation Starters. Workshop Curriculum: Tool 2. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-2/share-tool2.pdf.

1. Evans HP, Cooper A, Williams H, Carson-Stevens A. improving the safety of vaccine delivery. Human Vaccines & Immunotherapeutics2016; 12(5): 2164-5515 Online ISSN: 2164-554X

4962. Williams H, Cooper A, Carson-Stevens A. Opportunities for incident reporting. BMJ Quality Safety 2015; 25(2):133-4:bmjqs-2015-004962.; PMID:26558828

1. Trifir_o G, Coloma PM, Rijnbeek PR, Romio S, Mosseveld B, Weibel D, Bonhoeffer J, Schuemie M, van der Lei J, Sturkenboom M. Combining multiple healthcare databases for postmarketing drug and vaccine safety surveillance: why and how? J Intern Med 2014; 275:551-61

10. Koper, D et al. Frequency of medication errors in primary care patients with polypharmacy. Family Practice 2013; 30(30): 313-319 doi:10.1093/fampra/cms070

26. Thomsen, LA, Winterstein AG, Sondergaard B, Haugbolle LS, Melander A. S. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007; 41: 1411–26.

2012. Institute of Medicine (IOM). Health IT and Patient Safety: Building Safer Systems for Safer Care . Washington, DC: The National Academies Press, 2012.

10. Derek W Meeks, Michael W Smith, Lesley Taylor, Dean F Sittig, Jean M Scott, Hardeep Singh, An analysis of electronic health record-related patient safety concerns, Journal of the American Medical Informatics Association, Volume 21, Issue 6, November 2014, Pages 1053–1059, https://doi.org/10.1136/amiajnl-2013-002578

6. Agency for Healthcare Research and Quality. Health literacy universal precautions toolkit, 2nd https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool6.html

46. Joanne Callen, Andrew Georgiou, Julie Li, Johanna I Westbrook. The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better?2015 Jan; 26(1): 38–46. Published online 2015 Jan 27


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