Comment period on AHRQ Prototype Patient Safety Reporting System

Kuhn, Gloria gkuhn at MED.WAYNE.EDU
Sat Jun 15 11:24:23 UTC 2013


I agree with Bob Swerlick's comments.  The purpose of this reporting is fundamental to what this group recommends.

My perceptions as a patient or as a family member may not include all of the facts or knowledge of everything the healthcare provider has done.  If I as a patient give permission for records to be obtained I still may not know if they were read.  I may be unaware that tests were looked at and deemed unimportant.
I have profound respect for the perceptions of patients and families but I wonder what will be done with those perceptions to move study of diagnostic  error towards an area that can be studied?

Diagnosis is arguably the most complex aspect of practicing medicine.  It evolves over time and with input of increasing information.  It is not static in most cases.  To point at one particular point in time and say that is where the error occurred or that is where things began to go wrong is hard for even experts to determine.  

I look at all of you wrestling with the definition of error and wonder if the patient, knowing they are ill, but not knowing the cause of the illness, and frustrated by the physician's difficulty with diagnosing the illness is in the best position to call error.  Of course they can suggest and may be correct.  But who will study their comments and who will judge if the comments are "correct"?
Gloria Kuhn
Wayne State University 
Department of Emergency Medicine
________________________________________
From: Swerlick, Robert A [rswerli at EMORY.EDU]
Sent: Friday, June 14, 2013 5:11 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: Comment period on AHRQ Prototype Patient Safety Reporting System

I think we have to come to a common understanding of what the purpose of this reporting might be. We used a survey approach to attempt to identify errors in practice in Dermatology by asking physicians. We came up with a series of reports and then created a taxonomy after the fact. Some of the reports were deemed not errors. There were some surprises. It is viewed as a starting point for more quantitative studies.

We have considered looking at input from other stakeholders and have surveyed extenders. We have considered moving this out to survey administrators, nurses, and have discussed involving patients and their families. The purpose would not be to look for culpable parties, but to look for stakeholders who were observing important things which were not being observed by physicians.

I am not sure having the definitions iron clad at this point is really essential. If there are observations which patients make which they view as being errors and are alarming to them which we deem as not being errors, does this not still mean these are actionable in some sense?

I do think it is premature to ask for specific practice information.


Bob Swerlick

-----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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