Nancy C. Elder

Medical Management of Intimate Partner Violence Considering the Stages of Change: Precontemplation and Contemplation

BACKGROUND We undertook a study to understand how women who are victims of intimate partner violence (IPV) want physicians to manage these abusive relationships in the primary care office. METHODS Thirty-two mothers in IPV shelters or support groups in southwestern Ohio were interviewed to explore their abuse experiences and health care encounters retrospectively. The interviews were taped and transcribed. Using thematic analysis techniques, transcripts were read for indications of the stages of change and for participants’ desires concerning appropriate physician management. RESULTS Participants believed that physicians should screen women for IPV both on a routine basis and when symptoms indicating possible abuse are present, even if the victim does not disclose the abuse. Screening is an important tool to capture those women early in the process of victimization. When a victim does not recognize her relationship as abusive, participants recommended that physicians raise the issue by asking, but they also warned that doing more may alienate the victim. Participants also encouraged physicians to explore clues that victims might give about the abuse. In later contemplation, victims are willing to disclose the abuse and are exploring options. Physicians were encouraged to affirm the abuse, know local resources for IPV victims, make appropriate referrals, educate victims about how the abuse affects their health, and document the abuse. Participants identified a variety of internal and external factors that had affected their processes. CONCLUSIONS In hindsight, IPV victims recommended desired actions from physicians that could help them during early stages of coming to terms with their abusive relationships. Stage-matched interventions may help physicians manage IPV more effectively and avoid overloading the victim with information for which she is not ready.

The Identification of Medical Errors by Family Physicians During Outpatient Visits

BACKGROUND We wanted to describe errors and preventable adverse events identified by family physicians during the office-based clinical encounter and to determine the physicians’ perception of patient harm resulting from these events. METHOD We sampled Cincinnati area family physicians representing different practice locations and demographics. After each clinical encounter, physicians completed a form identifying process errors and preventable adverse events. Brief interviews were held with physicians to ascertain their perceptions of harm or potential harm to the patient. RESULTS Fifteen physicians in 7 practices completed forms for 351 outpatient visits. Errors and preventable adverse events were identified in 24% of these visits. There was wide variation in how often individual physicians identified errors (3% to 60% of visits). Office administration errors were most frequently noted. Harm was believe to have occurred as a result of 24% of the errors, and was a potential in another 70%. Although most harm was believed to be minor, there was disagreement as to whether to include emotional discomfort and wasted time as patient harm. CONCLUSIONS Family physicians identify errors and preventable adverse events frequently during patient visits, but there is variation in how some error categories are interpreted and how harm is defined.

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network

Context: Little is known about the types and outcomes of testing process errors that occur in primary care. Objective: To describe types, predictors and outcomes of testing errors reported by family physicians and office staff. Design: Events were reported anonymously. Each office completed a survey describing their testing processes prior to event reporting. Setting and participants: 243 clinicians and office staff of eight family medicine offices. Main outcome measures: Distribution of error types, associations with potential predictors; predictors of harm and consequences of the errors. Results: Participants submitted 590 event reports with 966 testing process errors. Errors occurred in ordering tests (12.9%), implementing tests (17.9%), reporting results to clinicians (24.6%), clinicians responding to results (6.6%), notifying patient of results (6.8%), general administration (17.6%), communication (5.7%) and other categories (7.8%). Charting or filing errors accounted for 14.5% of errors. Significant associations (p<0.05) existed between error types and type of reporter (clinician or staff), number of labs used by the practice, absence of a results follow-up system and patients’ race/ethnicity. Adverse consequences included time lost and financial consequences (22%), delays in care (24%), pain/suffering (11%) and adverse clinical consequence (2%). Patients were unharmed in 54% of events; 18% resulted in some harm, and harm status was unknown for 28%. Using multilevel logistic regression analyses, adverse consequences or harm were more common in events that were clinician-reported, involved patients aged 45–64 years and involved test implementation errors. Minority patients were more likely than white, non-Hispanic patients to suffer adverse consequences or harm. Conclusions: Errors occur throughout the testing process, most commonly involving test implementation and reporting results to clinicians. While significant physical harm was rare, adverse consequences for patients were common. The higher prevalence of harm and adverse consequences for minority patients is a troubling disparity needing further investigation.

Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Context: Reporting of medical errors is a widely recognized mechanism for initiating patient safety improvement, yet we know little about the feasibility of error reporting in physician offices, where the majority of medical care in the United States is rendered. Objective: To identify barriers and motivators for error reporting by family physicians and their office staff based on the experiences of those participating in a testing process error reporting study. Design: Qualitative focus group study, analyzed using the editing method. Setting: Eight volunteer practices of the American Academy of Family Physicians National Research Network. Participants: 139 physicians, nurse practitioners, physician assistants, nurses, and staff who took part in 18 focus groups. Instrument: Interview questions asked about making reports, what prevents more reports from being made, and decisions about when to make reports. Results: Four factors were seen as central to making error reports: the burden of effort to report, clarity regarding the information requested in an error report, the perceived benefit to the reporter, and properties of the error (eg, severity, responsibility). The most commonly mentioned barriers were related to the high burden of effort to report and lack of clarity regarding the requested information. The most commonly mentioned motivator was perceived benefit. Conclusion: Successful error reporting systems for physicians’ offices will need to have low reporting burden, have great clarity regarding the information requested, provide direct benefit through feedback useful to reporters, and take into account error severity and personal responsibility.

Management of Test Results in Family Medicine Offices

PURPOSE We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management. METHODS Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes. RESULTS We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness—a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption—the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements). CONCLUSION Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.

Intensive care unit nurses’ perceptions of safety after a highly specific safety intervention

Background: It is unknown if successful changes in specific safety practices in the intensive care unit (ICU) generalise to broader concepts of patient safety by staff nurses. Objective: To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital acquired infections. Method: After implementation of practices that reduced catheter-related bloodstream infections in ICUs at four community hospitals, ICU nurses participated in focus groups to discuss patient safety. Audiotapes from the focus groups were transcribed, and two independent reviewers categorised the data which were triangulated with responses from selected questions of safety climate surveys and with the safety checklists used by management leadership on walk rounds. Results: Thirty-three nurses attended eight focus groups; 92 nurses and managers completed safety climate surveys, and three separate leadership checklists were reviewed. In focus groups, nurses predominantly related patient safety to dangers in the physical environment (eg, bed rails, alarms, restraints, equipment, etc.) and to medication administration. These areas also represented 47% of checklist items from leadership walk rounds. Nurses most frequently mentioned self-initiated “double checking” as their main safety task. Focus-group participants and survey responses both noted inconsistency between management’s verbal and written commitment compared with their day-to-day support of patient safety issues. Conclusions: ICU nurses who participated in a project to decrease hospital acquired infections did not generalise their experience to other aspects of patient safety or relate it to management’s interest in patient safety. These findings are consistent with many adult learning theories, where self-initiated tasks, combined with immediate, but temporary problem-solving, are stronger learning forces than management-led activities with delayed feedback.

Nurses’ Perceptions of Error Communication and Reporting in the Intensive Care Unit

Objectives: To describe models of nursing communication about medical error. Methods: Intensive care unit nurses at 4 hospitals that had implemented evidence-based practices to reduce hospital-acquired infections participated in focus groups. They discussed medical error decision making regarding formal reporting, telling someone else about a mistake, or keeping silence. From transcripts, we identified categories and grouped thematic elements; we then triangulated focus group findings with results from a safety culture survey completed by a random sample of nurses from those same intensive care units. Using all sources of data, models of communication were developed. Results: Thirty-three nurses attended 8 focus groups, and 92 nurses completed the surveys. Focus group nurses remained conflicted about reporting error, using time pressure, and the presence or absence of actual patient harm to prioritize formal reporting. Nurse-reported feedback was rare following formal reports of error. In contrast, responses from the safety culture survey revealed socially desirable answers, with a majority of nurses reporting that they usually or always reported errors and received feedback. Nurses are strongly conflicted about disclosing their errors to peers and physicians. Nurses preferred reporting witnessed errors to their supervisor rather than confronting the peer and used complex maneuvering when communicating with physicians about physician error. Conclusions: Medical error distresses nurses who are conflicted about disclosing, discussing, and reporting it. Lack of feedback from administration regarding reported errors reinforces the sense that reporting is not useful. Recognizing the barriers to learning about safety from reporting and the need for visibility in communicating lessons from errors is essential as hospitals strive for safe patient care.

How Experiencing Preventable Medical Problems Changed Patients’ Interactions With Primary Health Care

PURPOSE We wanted to explore how patients’ experiences with preventable problems in primary care have changed their behavioral interactions with the health care system. METHODS We conducted semistructured interviews with 24 primary care patients, asking them to describe their experiences with self-perceived preventable problems. We analyzed these interviews using the editing method and classified emotional and behavioral responses to experiencing preventable problems. RESULTS Anger was the most common emotional response, followed by mistrust and resignation. We classified participants’ behavioral responses into 4 categories: avoidance (eg, stop going to the doctor), accommodation (eg, learn to deal with delays), anticipation (eg, attend to details, attend to own emotions, acquire knowledge, actively communicate), and advocacy (eg, get a second opinion). CONCLUSIONS Understanding how patients react to their experiences with preventable problems can assist health care at both the physician-patient and system levels. We propose an association of mistrust with the behaviors of avoidance and advocacy, and suggest that further research explore the potential impact these patient behaviors have on the provision of health care.

Learning from different lenses: Reports of medical errors in primary care by clinicians, staff, and patients - A project of the American academy of family physicians national research network

Objectives: To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report. Methods: Clinicians, staff, and patients in 10 family medicine clinics of the American Academy of Family Physicians National Research Network representing a diversity of clinical and community settings were invited to report errors they observed. They were asked to report routinely during 10 weeks and to report every error on 5 specific days. They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system. Results: Four hundred one clinicians and staff reported 935 errors within 717 events, 37% (265) of which came from the 5 intensive reporting days and 61% (440) from routine reports. Staff made 384 (53%) reports, and clinicians, 342 (47%) reports. Most (96%) errors reported were process errors, not related to knowledge or skill. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Reports suggest that patients with complex health issues (31% versus 20%, P = 0.013) are vulnerable to more severe outcomes. Patients submitted 126 reports, 18 of which included errors. Conclusions: Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors. There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff.

Rural Community Members’ Perceptions of Harm from Medical Mistakes: A High Plains Research Network (HPRN) Study

Objective: The aim of this study was to learn about community members’ definitions and types of harm from medical mistakes. Methods: Mixed methods study using community-based participatory research (CBPR). The High Plains Research Network (HPRN) with its Community Advisory Council (CAC) designed and distributed an anonymous survey through local community newspapers. Survey included open-ended questions on patients’ experiences with medical mistakes and resultant harm. Qualitative analysis was performed by CAC and research team members on mistake descriptions and types of reported harm. Patient Safety Taxonomy coding was performed on a subset of surveys that contained actual medical errors. Results: A total of 286 surveys were returned, with 172 respondents (60%) reporting a total of 180 perceived medical mistakes. Quantitative analysis showed that 41% of perceived mistakes (n = 73) involved only unanticipated outcomes. Reported types of harm included emotional, financial, and physical harm. Reports suggest that perceived clinician indifference to unanticipated outcomes may lead to patients’ loss of trust and belief that the unexpected outcome was a result of an error. Discussion: CBPR methodology is an important strategy to design and implement a community-based survey. Community members reported experiencing medical mistakes, most with harmful outcomes. The response they received by the medical community may have influenced their perception of mistake and harm.