Comment period on AHRQ Prototype Patient Safety Reporting System

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Fri Jun 14 06:24:00 UTC 2013


I think that the definition of error is too limited in the ambulatory 
setting.
1) the definition limits this to something done or not done by a health 
care provider.  So, this would not include something done or not done by 
the system (e.g. a skin biopsy is lost in transportation).  This also does 
not include errors by the patient.  So, if a patient is told to get a 
follow up PSA and the patient forgets, this is not necessarily counted. 
2)  The definition also says that the something done or not done was at 
the time considered incorrect..  I think this is also wrong.  So, for 
example that there is controversy in the medical literature and a doctor 
makes an incorrect  diagnosis because medical knowledge at the time is 
unclear.    This is still an error from the patients point of view. 
Perhaps the doc or the profession did not read the literature critically 
enough.  Perhaps the publilshed literature was biased because of drug 
company influence, publication bias, ect.   To me, that is part of the 
"system" of health care.  The definition seems to look at the individual 
and not the system in which the individual works in.   This, of course, 
takes a very broad view of "system"

Michael Kanter, M.D.
Regional Medical Director of Quality & Clinical Analysis
(626) 405-5722 (tie line 8+335)
THRIVE By Getting Regular Exercise

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From:   "Graber, Mark" <Mark.Graber at VA.GOV>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   06/13/2013 08:42 AM
Subject:        Comment period on AHRQ Prototype Patient Safety Reporting 
System




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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