Comment period on AHRQ Prototype Patient Safety Reporting System

William.Strull at KP.ORG William.Strull at KP.ORG
Fri Jun 14 14:26:44 UTC 2013


I agree with most of the comments that this definition seems too narrowly 
focused on the "health care provider."  For the diagnosis questions, I'd 
suggest the changes in bold:

A delay or mistake related to a diagnosis or advice that you were given.

In your opinion, how or why did the mistake or delay in diagnosis or 
medical advice occur?

Do you think the correct diagnosis could or should have been made sooner?


William Strull MD
Medical Director, Quality and Patient Safety
Kaiser Permanente

The Permanente Federation, LLC
One Kaiser Plaza, 23B
Oakland, California 94612
510-271-5987 (office)
8-423-5987 (tie-line)
510-271-6642 (fax)
415-601-6013 (mobile phone)

Debra C. Costa (assistant)
debra.c.costa at kp.org
510-271-6031

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From:   "Graber, Mark" <Mark.Graber at VA.GOV>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   06/13/2013 08:56 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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