Comment period on AHRQ Prototype Patient Safety Reporting System

Taylor, Julie (CDC/OSELS/LSPPPO) czt7 at CDC.GOV
Fri Jun 14 14:02:32 UTC 2013


Mark,
I looked through the questionnaire and did not see where someone would record a mistake that was due to a misinterpretation of a test result.  It would be an event where the right test was ordered, the results were accurate, and the physician received the results; but the physician provided the wrong medical advice because of a misinterpretation of the results.  I found the "f. The test results were lost and the patient did not receive them."   Could you add something like, "the test results were received; but the medical advice provided from the test result was incorrect?"
I understand that this may not be easy to identify.  This information would help us focus our efforts to improve patient safety.
Thank you for the opportunity to comment.
Julie

-----Original Message-----
From: Graber, Mark [mailto:Mark.Graber at VA.GOV] 
Sent: Thursday, June 13, 2013 11:37 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
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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