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Using Reported Primary Care Errors to Develop and Implement Patient Safety Interventions: A Report from the ASIPS Collaborative.

Editors

In: Henriksen K1, Battles JB1, Marks ES2, Lewin DI1, editors.

Source

Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.
Advances in Patient Safety.

Author information

1
Agency for Healthcare Research and Quality
2
US Department of Defense
3
All of the authors are affiliated with the University of Colorado Health Sciences Center, Department of Family Medicine, Aurora, CO. One author is also affiliated with the University of Colorado Health Sciences Center School of Pharmacy, Denver, CO (LH); another author is also affiliated with the Denver Health and Hospital Authority, Denver, CO (BM)

Excerpt

Background and objectives: Approaches to translating medical error information into effective interventions have not been well described. The Applied Strategies for Improving Patient Safety (ASIPS) Collaborative developed a mixed-methods approach to analyze medical errors to (1) develop an initial conceptual framework for depicting specific clinical processes at risk for error, (2) validate the framework through critical inquiry with clinicians and staff from participating practices and through concurrent analysis of malpractice insurance data, and (3) implement practice-specific quality improvement interventions to reduce medical errors. Methods: We identified two areas for possible practice-level intervention: laboratory errors and prescription errors. Expert panels of local stakeholders provided grounded input into the refinement of the frameworks and causal flows, resulting in the development of realistic “principles for process improvement” (PPIs) for developing flexible and locally relevant interventions. Results: The intervention for laboratory tests involved the use of a portable bar coding utility to support an electronic laboratory test tracking system. The prescription/medication interventions were based upon an electronic mechanism designed to ensure timely and accurate transmittal of prescription data from practices to pharmacies; incorporate important data elements such as the purpose/indication on each prescription; and develop timely, accurate, and accessible medication lists for the medical record. Conclusion: Using multiple data sources, locally developed and relevant quality improvement interventions to improve patient safety can be successfully implemented in primary care. However, a clear understanding of the processes that require change is essential to successfully address implementation challenges and put interventions into routine use.

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