Comment period on AHRQ Prototype Patient Safety Reporting System

Robert McNutt Robert_McNutt at RUSH.EDU
Fri Jun 14 14:28:57 UTC 2013


Wouldn’t it be nice if AHRQ was more interested in what works well? Wouldn’t it be nice if AHRQ was there to support the cottage industry of a physician/patient pair through thick and thin? Wouldn’t it be nice if AHRQ destroyed the cross-sectional episodic view of right and wrong? Wouldn’t it be nice if we realized that improvement was more important than punishment? Interesting how this is all playing out. I like your points; Error? Mistake? Perspective? Whose? How good can we be? How good should we be? Who is watching the watchers?


From: Michael.H.Kanter at KP.ORG [mailto:Michael.H.Kanter at KP.ORG]
Sent: Friday, June 14, 2013 1:24 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Comment period on AHRQ Prototype Patient Safety Reporting System

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<mailto:Mark.Graber at VA.GOV>>
To:        IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto: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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