Comment period on AHRQ Prototype Patient Safety Reporting System

Meredith Makeham m.makeham at UNSW.EDU.AU
Thu Jun 13 22:29:42 UTC 2013


Hi Mark,
Fantastic to hear that the system is getting up.  

My initial thought on the definition is that the phrase 'at the time it happened' could be a little ambiguous and may cause trouble.  Often things happen that the whole medical team and the patient think are correct, but it turns out later they were all wrong, and you could interpret that definition as excluding those types of events.  

Would the definition stand as well if this was left off?

Regards Meredith Makeham 


On 14/06/2013, at 1:42 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!
> 
> Mark
> 
> 
> Here’s the 3 main issues:
> 
> 1)  Their definition of error:   Does this adequately apply to diagnostic error?
> “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:
> http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201306-0935-001&icID=207255
> 
> 
> 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 3.1.1.1
> 
> □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 3.1.2.1
> 
> □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 3.1.3.1
> 
> □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]
> 
> 
> 3.1.3.1 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?
> 
> http://www.reginfo.gov/public/do/PRAViewIC?ref_nbr=201306-0935-001&icID=207256
> 
> 
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