Study finds a wide variety of errors in testing process at family medicine clinics

Bad outcomes more common for minority patients

August 13, 2008

The largest study to date of testing errors reported by family physician offices in the United States found that problems occur throughout the testing process and disproportionately affect minority patients.

In the June 2008 issue of Quality & Safety in Health Care, the researchers report that medical testing errors led to lost time, lost money, delays in care, and pain and suffering for patients, with adverse consequences affecting minority patients far more often.

"I think everybody has had an occasion where their physician did a test, and they just didn't hear back," said John Hickner, MD, professor and vice chair of family medicine at the University of Chicago Medical Center. "People identify that as a common experience. The incident reports we received voluntarily from family physicians and their office staff detail what the problem areas are."

"There's a fair amount of risk and harm that results from testing mistakes and slips," he added. "This data provides a starting point for improvement."

The study took place at eight family physician offices--all part of the American Academy of Family Physicians National Research Network. Four of the doctors' offices were rural, three urban and one suburban.

During 32 weeks in 2004, 243 clinicians and office staff submitted 590 anonymous reports describing 966 medical-test-related errors. The tests included lab work, diagnostic imaging and other tests such as pulmonary function tests and electrocardiograms.

Errors were classified in one of 10 categories: test ordering, test implementation, reporting results to the clinician, clinician responding to results, notifying the patient of results, administrative, treatments, communications, other process errors, and knowledge and skills.

The most common errors involved failure to report results to the clinician, accounting for one out of four (24.6%) reported mistakes. Test implementation (17.9%) and administrative errors (17.6%) were the next most common.

Test implementation errors were nearly double for minority groups, at 32 percent versus 18 percent for non-Hispanic whites. The investigators believe this may reflect difficulties with transportation to the testing site or lack of insurance to pay for the test.

A quarter of the errors resulted in delays in care for patients, and 13 percent caused pain, suffering or a definite adverse clinical consequence. Eighteen percent resulted in harm.

"One of the most striking and disturbing findings was that minority patients were nearly three times more likely to experience adverse consequences," Hickner said, and twice as likely to experience physical harm from errors.

The researchers reported considerable variation in the types of errors reported from each practice. "While significant physical harm was rare, adverse consequences for patients were common," Hickner observed. "This study strongly supports the need for office-by-office improvements in the overall testing process within primary care."

Although this study was not designed to determine the true error rate, "testing-process errors appear to be common," the authors conclude. "Since many errors are undetected or unreported, we can assume this is an extreme lower bound."

An accompanying paper in the same journal from the same study looked at how often harm to patients was prevented or reduced by early detection and intervention. About 25 percent of the errors were discovered in time for an intervention, usually by physicians. "This demonstrates the continuing importance of people," the authors note, "and cautions against the over-reliance on current technological systems."

The study was funded in part by the Agency for Health Care Research and Quality. Additional authors include Deborah Graham and Elias Brandt of the American Academy of Family Physicians National Research Network, Nancy Elder of the University of Cincinnati, Caroline Emsermann of the University of Colorado, Susan Dovey of the Royal New Zealand College of General Practitioners and Robert Phillips of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. Elizabeth Staton, University of Colorado, contributed to the error-mitigation paper.

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