Comment period on AHRQ Prototype Patient Safety Reporting System
peggyzuckerman at GMAIL.COM
Fri Jun 14 00:31:35 UTC 2013
I have a little trouble with the wording of the description of a medical
mistake or error as to the phrase "that would be considered incorrect at
the time". If a mistake occurs for lack of information that was available
but not utilized, would that be included. Assuming that it is a patient
answering this, who would assess this for the patient? If an error was
made, but all involved parties thought it to be correct at the time--the
opposite of above--would mistakes made due to use of obsolete procedures be
This may be parsing words, but I feel that the description is rather
limiting to all the elements that could lead to a medical error. Certainly
this definition would not include misdiagnosis in many instances--as all
parties did agree to proceed under the assumption that nothing was
incorrect at that time. This comes down to a cry of "How was supposed to
know?" or similar. We need to be able to answer what was "supposed" to
have been known at that time.
In the instructions, the prompts push the patient to skip over certain
sub-questions, For example, 3.1.f1 "What was the mistake?" is followed by
a text box, and a "Go to 3.2" This does not permit the description of the
medicine which requested in 22.214.171.124.
Hope that the instructions will be written NOT in all caps, for greater
On Thu, Jun 13, 2013 at 8:37 AM, Graber, Mark <Mark.Graber at va.gov> wrote:
> Dear colleagues,
> As many of you may know, AHRQ is supporting the development of a national
> reporting system that patients could use to identify their concerns. The
> prototype is just about ready to go, and AHRQ is accepting one final set of
> comments (by July 8th). SIDM will be submitting a unified set of comments,
> and I’d really appreciate your input. Thanks for your suggestions!
> Here’s the 3 main issues:
> 1) Their definition of error: Does this adequately apply to diagnostic
> “A medical mistake or error is something that was done (or not done) by a
> health care provider that would be considered incorrect at the time it
> happened. Sometimes medical mistakes can result in harm or injury to the
> patient, but not every time.”
> 2) The questions the patient will be asked: Are these 2 questions
> sufficient to identify, classify and study diagnostic error?
> See the full questionaire at:
> 3.1 Did the medical mistake or error involve any of the following? Please
> choose the one answer that fits best.
> □A A mistake related to a medicine
> Medicines can include prescription or non-prescription medication, herbs,
> dietary supplements, vaccines, contrast dye or other injected medicines] à
> GO TO 126.96.36.199
> □B A mistake related to a test, procedure, or surgery
> This includes tests that involve taking samples of skin or tissue,
> inserting tubes to examine internal parts of your body, or other tests
> involving blood, urine, or X-rays.] à GO TO 188.8.131.52
> □C A mistake related to pregnancy or childbirth
> This includes errors in diagnostic testing during pregnancy and errors
> during labor and delivery] à GO TO 3.2
> □D A mistake related to a diagnosis or advice from a doctor, nurse, or
> other health care provider à GO TO 184.108.40.206
> □E A mistake related to poor cleanliness or poor hygiene à GO TO 3.2
> □F Something else, or more than one mistake [GO TO 3.1f1]
> 220.127.116.11 In your opinion, what was the mistake with the diagnosis or
> medical advice?
> 3) The questions the physician will be asked: Are the questions asked
> sufficient to classify and study diagnostic error?
> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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