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Research ArticleOriginal Research

Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes

Steven Crane, Philip D. Sloane, Nancy Elder, Lauren Cohen, Natascha Laughtenschlaeger, Kathleen Walsh and Sheryl Zimmerman
The Journal of the American Board of Family Medicine July 2015, 28 (4) 452-460; DOI: https://doi.org/10.3122/jabfm.2015.04.140050
Steven Crane
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
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Philip D. Sloane
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
MD
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Nancy Elder
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
MD
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Lauren Cohen
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
MA
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Natascha Laughtenschlaeger
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
MD
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Kathleen Walsh
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
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Sheryl Zimmerman
From the Mountain Area Health Education Center, Asheville, NC (SC, NL, KW); the Cecil G. Sheps Center for Health Services Research (PDS, LC, SZ), and Department of Family Medicine and School of Medicine (PS), and School of Social Work (SZ), University of North Carolina—Chapel Hill, Chapel Hill and the University of Cincinnati, Cincinnati, OH (NE).
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    Table 1. Description of the Study Practices
    Type of practicen (%)
        Private1 (14.3)
        Part of a hospital system or other health system3 (42.9)
        Community health center1 (14.3)
        County health department1 (14.3)
        Residency program1 (14.3)
    Primary medical specialty representedn (%)
        Family medicine6 (85.7)
        Pediatrics1 (14.3)
    Number of Providers (full-time equivalents)Mean (SD); Range
        Physicians3.9 (2.8); 1–8.75
        Nurse practitioner or physician assistants2.8 (2.3); 0.5–5.6
        Physicians-in-training (residents)5.2 (10.2); 0–27
    Services providedn (%)
        Pediatric care7 (100)
        Obstetric care3 (42.9)
        Geriatric care5 (71.4)
    Number of Patient Encounters Per YearMean (SD); Range
        Outpatient medical visits22,589 (11,258.6); 10,000–36,000
        Inpatient visits3,433 (2,528.6); 0–5,688
        Obstetric deliveries230 (122.4); 0–315
        Behavioral health visits2,584 (1,835.0); 0–4,637
        Nursing home visits1,077 (748.5); 0–2,000
        Home visits41.6 (74.6); 0–185
    Predominant medical record system for office visitsn (%)
        Paper1 (14.3)
        Electronic6 (85.7)
    Percentage of Annual Patient Visits, by Age CategoryMean (SD); Range
        < 18 years52 (44.0); 10–100
        18–64 years47 (31.2); 0–75
        ≥ 65 years16 (17.8); 0–50
    Percentage of Annual Patient Visits, by Payer StatusMean (SD); Range
        Private insurance27 (23.4); 0–70
        HMO3 (8.0); 0–22
        Medicare26 (23.2); 0–60
        Medicaid22 (14.5); 0–45
        Self-pay11 (15.1); 0–45
        Charity11 (23.1); 0–63
    Percentage of Annual Visits by Patient Race/EthnicityMean (SD); Range
        White88 (9.1); 75–95
        African American9 (6.2); 4–20
        American Indian0 (0.8); 0–2
        Asian1 (1.8); 0–5
        Other2 (3.3); 0–9
        Hispanic or Latino Ethnicity16 (18.8); 1–40
    • SD, standard deviation.

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    Table 2. Frequency of Near Miss Events Overall and by Participating Primary Care Practice
    Near Miss EventNumber of Near Miss Events (% of Reports, by Site)
    All Practices (n=632)Practice A (n=43)Practice B (n=177)Practice C (n=80)Practice D (n=139)Practice E (n=69)Practice F (n=43)Practice G (n=81)
    Office Process Problem
        Filinga160 (25.3)7 (16.3)72 (40.7)25 (31.3)18 (13.0)7 (10.1)15 (34.9)16 (19.8)
        Chart dataa95 (15.0)6 (14.0)20 (11.3)12 (15.0)14 (10.1)10 (14.5)4 (9.3)29 (35.8)
        Patient flow14 (2.2)1 (2.3)2 (1.1)3 (3.8)5 (3.6)1 (1.5)1 (2.3)1 (1.2)
        Appointment or referral30 (4.8)1 (2.3)4 (2.3)3 (3.8)14 (10.1)7 (10.1)1 (2.3)—
    Equipment or Building Problem
        Equipment and physical building/surroundings/practice site8 (1.3)—2 (1.1)1 (1.3)3 (2.2)2 (2.9)——
        Other specific problems with computer8 (1.3)—1 (0.6)—4 (2.9)3 (4.4)——
    Investigations
        Ordering investigations39 (6.2)8 (18.6)6 (3.4)5 (6.3)4 (2.9)8 (11.6)5 (11.6)3 (3.7)
        Implementing investigations45 (7.1)2 (4.7)9 (5.1)14 (17.5)13 (9.4)4 (5.8)—3 (3.7)
        Reporting investigations77 (12.2)1 (2.3)16 (9.0)4 (5.0)12 (8.6)8 (11.6)12 (27.9)24 (29.6)
    Medications or Other Treatments
        Ordering medications or treatmentsa55 (8.7)8 (18.6)22 (12.4)—18 (13.0)2 (2.9)3 (7.0)2 (2.5)
        Dispensing medications or implementing treatments36 (5.7)4 (9.3)14 (7.9)1 (1.3)11 (7.9)6 (8.7)——
    Communication
        Communication with patients30 (4.8)1 (2.3)6 (3.4)8 (10.0)8 (5.8)5 (7.3)2 (4.7)—
        Communication with other healthcare providers sharing patient carea23 (3.6)3 (7.0)2 (1.1)2 (2.5)10 (7.2)3 (4.4)—3 (3.7)
    Clinical Knowledge or Performance
        Failure to follow standard or recommended practice12 (1.9)1 (2.3)1 (0.6)2 (2.5)5 (3.6)3 (4.4)——
    • ↵a Across all practices, 21.9% (filing), 28.4% (chart data), 40.0% (ordering medications or treatments), and 4.3% (communication with other healthcare providers sharing patient care) of these near misses were secondarily attributable to an EMR-related problem.

    • View popup
    Table 3. Perceived Severity and Estimated Cost of Selected Near Miss Events in Seven Primary Care Practices
    Code# of ReportsEvent DescriptionSeverity Ratinga Mean (SD)Likelihood of Adverse Event if Near Miss not Identifiedb n (%)Potential Financial Cost of Event to Patientb n (%)Estimated Financial Cost of Event to Practiceb n (%)
    Five Most Common Near Miss Events
    1.1.1160Filing problems51.8 (30.7)38 (23.8)12 (7.5)5 (3.1)
    1.1.295Chart data problems35.4 (29.9)11 (11.6)8 (8.4)4 (4.2)
    1.3.245Implementing investigations52.2 (28.2)10 (22.2)4 (8.9)3 (6.7)
    1.3.377Reporting investigations72.0 (28.3)38 (49.4)17 (22.1)1 (1.3)
    1.4.155Ordering medication or treatments59.1 (29.3)17 (30.9)6 (10.9)5 (9.1)
    Five Near Miss Events Rated Most Potentially Severe
    1.2.18Other specific problems with computer59.2 (25.2)5 (62.5)1 (12.5)0 (0)
    1.3.377Reporting investigations72.0 (28.3)38 (49.4)17 (22.1)1 (1.30)
    1.4.155Ordering medications or treatments59.1 (29.3)17(30.9)6 (10.9)5 (9.1)
    1.4.236Dispensing medications or implementing treatments63.0 (31.0)16 (44.4)11 (30.6)3 (8.3)
    2.112Failure to follow standard or recommended practice56.5 (21.7)2 (16.7)3 (25.0)1 (8.3)
    Fivec Near Miss Events Rated Most Potentially Costly to the Practice
    1.1.430Appointment or referral46.1 (28.6)6 (20.0)4 (13.3)
    1.28Equipment and physical building/surroundings/practice site49.7 (31.8)2 (25.0)1 (12.5)
    1.3.245Implementing investigations52.2 (28.2)10 (22.2)4 (8.9)
    1.4.155Ordering medication or treatments59.1 (29.3)17 (30.9)6 (10.9)
    1.4.236Dispensing medications or implementing treatments63.0 (31.0)2 (44.4)11 (30.6)
    2.112Failure to follow standard or recommended practice56.5 (21.7)2 (16.7)3 (25.0)
    • ↵a On a scale of 0–100, where 0=not very serious and 100=extremely serious.

    • ↵b Rated categorically with 0 = none/minimal; 1 = some; 2 = a lot. Percent reflects ‘A lot’ responses within each error type.

    • ↵c Two events tied for fifth most costly.

    • SD, standard deviation.

    • View popup
    Table 4. Summary of Practice Improvement Projects Implemented by Participating Primary Care Practices during the Study Period
    Primary Care Practice
    ABCDEFG
    Length of study period in months8989966
    Number of Practice Improvement ProjectsInitiated66231511
    Completed in study period0000701
    Still in process at end of study period6011410
    On hold at end of study period0111000
    Inactivated during study period0501400
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The Journal of the American Board of Family     Medicine: 28 (4)
The Journal of the American Board of Family Medicine
Vol. 28, Issue 4
July-August 2015
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Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes
Steven Crane, Philip D. Sloane, Nancy Elder, Lauren Cohen, Natascha Laughtenschlaeger, Kathleen Walsh, Sheryl Zimmerman
The Journal of the American Board of Family Medicine Jul 2015, 28 (4) 452-460; DOI: 10.3122/jabfm.2015.04.140050

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Reporting and Using Near-miss Events to Improve Patient Safety in Diverse Primary Care Practices: A Collaborative Approach to Learning from Our Mistakes
Steven Crane, Philip D. Sloane, Nancy Elder, Lauren Cohen, Natascha Laughtenschlaeger, Kathleen Walsh, Sheryl Zimmerman
The Journal of the American Board of Family Medicine Jul 2015, 28 (4) 452-460; DOI: 10.3122/jabfm.2015.04.140050
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