Research ArticleOriginal Research

Primary Care Providers’ Perspectives on Errors of Omission

Lusine Poghosyan, Allison A. Norful, Elaine Fleck, Jean-Marie Bruzzese, AkkeNeel Talsma and Angela Nannini
The Journal of the American Board of Family Medicine November 2017, 30 (6) 733-742; DOI: https://doi.org/10.3122/jabfm.2017.06.170161

References

  1. 1.↵
    1. Hammons T,
    2. Piland NF,
    3. Small SD,
    4. Hatlie MJ,
    5. Burstin HR
    . Ambulatory patient safety. What we know and need to know. J Ambul Care Manage 2003;26:63–82.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Panesar S,
    2. deSilva D,
    3. Carson-Stevens A,
    4. Cresswell K,
    5. Salvilla S,
    6. Slight S
    . How safe is primary care? A systematic review. BMJ Qual Saf 2016;5:544–553.
    OpenUrl
  3. 3.↵
    1. Bishop TF,
    2. Ryan AM,
    3. Casalino LP
    . Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011;305:2427–2431.
    OpenUrlCrossRefPubMedWeb of Science
  4. 4.↵
    1. Phillips RL Jr.,
    2. Bartholomew LA,
    3. Dovey SM,
    4. Fryer GE Jr.,
    5. Miyoshi TJ,
    6. Green LA
    . Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care 2004;13:121–126.
    OpenUrlAbstract/FREE Full Text
  5. 5.↵
    1. Wilson T,
    2. Pringle M,
    3. Sheikh A
    . Promoting patient safety in primary care. BMJ 2001;323:583–584.
    OpenUrlFREE Full Text
  6. 6.↵
    1. Sandars J,
    2. Esmail A
    . The frequency and nature of medical error in primary care: Understanding the diversity across studies. Fam Pract 2003;20:231–236.
    OpenUrlCrossRefPubMedWeb of Science
  7. 7.↵
    1. Thammasitboon S,
    2. Thammasitboon S,
    3. Singhal G
    . System-related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care 2013;43:242–247.
    OpenUrl
  8. 8.↵
    1. Hofmann D,
    2. Mark D
    . An investigation of the relationship between safety climate and medication errors as well as other nurse patient outcomes. Personnel Psychology 2006;59:847–869.
    OpenUrlCrossRef
  9. 9.↵
    1. Saber Tehrani AS,
    2. Lee H,
    3. Mathews SC,
    4. Shore A,
    5. Makary MA,
    6. Pronovost PJ,
    7. Newman-Toker DE
    . 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013;22:672–680.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Wessell AM,
    2. Litvin C,
    3. Jenkins RG,
    4. Nietert PJ,
    5. Nemeth LS,
    6. Ornstein SM
    . Medication prescribing and monitoring errors in primary care: A report from the Practice Partner Research Network. Qual Saf Health Care 2010;19(5):e21.
    OpenUrlAbstract/FREE Full Text
  11. 11.↵
    1. Kalisch BJ,
    2. Lee KH
    . Missed nursing care: Magnet versus non-Magnet hospitals. Nurs Outlook 2012;60(5):e32–e39.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Sheppard JP,
    2. Fletcher K,
    3. McManus RJ,
    4. Mant J
    . Missed opportunities in prevention of cardiovascular disease in primary care: A cross-sectional study. Br J Gen Pract 2014;64(618):e38–e46.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Taub N,
    2. Baker R,
    3. Khunti K,
    4. et al
    . Patient safety systems in the primary health care of diabetes—A story of missed opportunities? Diabet Med 2010;27:1322–1326.
    OpenUrlPubMed
  14. 14.↵
    1. Taylor CR,
    2. Hepworth JT,
    3. Buerhaus PI,
    4. Dittus R,
    5. Speroff T
    . Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. Qual Saf Health Care 2007;16:244–247.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. Graudins LV,
    2. Ingram C,
    3. Smith BT,
    4. Ewing WJ,
    5. Vandevreede M
    . Multicentre study to develop a medication safety package for decreasing inpatient harm from omission of time-critical medications. Int J Qual Health Care 2015;27:67–74.
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Molfenter T,
    2. Zetts C,
    3. Dodd M,
    4. Owens B,
    5. Ford J,
    6. McCarty D
    . Reducing errors of omission in chronic disease management. J Interprof Care 2005;19:521–523.
    OpenUrlPubMed
  17. 17.↵
    1. Bittner NP,
    2. Gravlin G,
    3. Hansten R,
    4. Kalisch BJ
    . Unraveling care omissions. J Nurs Adm 2011;41:510–512.
    OpenUrlPubMed
  18. 18.↵
    1. Ausserhofer D,
    2. Zander B,
    3. Busse R,
    4. et al
    . Prevalence, patterns and predictors of nursing care left undone in European hospitals: Results from the multicountry cross-sectional RN4CAST study. BMJ Qual Saf 2014;23:126–135.
    OpenUrlAbstract/FREE Full Text
  19. 19.↵
    1. Weingart SN,
    2. Wilson RM,
    3. Gibberd RW,
    4. Harrison B
    . Epidemiology of medical error. BMJ 2000;320:774–777.
    OpenUrlFREE Full Text
  20. 20.↵
    1. Jones TL,
    2. Hamilton P,
    3. Murry N
    . Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. Int J Nurs Stud 2015;52:1121–1137.
    OpenUrlCrossRefPubMed
  21. 21.↵
    1. Kalisch BJ
    . Errors of omission: How missed nursing care imperils patients. Washington, DC: American Nurses Association; 2015.
  22. 22.↵
    1. Lake ET,
    2. Germack HD,
    3. Viscardi MK
    . Missed nursing care is linked to patient satisfaction: A cross-sectional study of US hospitals. BMJ Qual Saf 2016;25:535–543.
    OpenUrlAbstract/FREE Full Text
  23. 23.↵
    1. Carthon JM,
    2. Lasater KB,
    3. Sloane DM,
    4. Kutney-Lee A
    . The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: A cross-sectional study of US hospitals. BMJ Qual Saf 2015;24:255–263.
    OpenUrlAbstract/FREE Full Text
  24. 24.↵
    1. Nelson ST,
    2. Flynn L
    . Relationship between missed care and urinary tract infections in nursing homes. Geriatr Nurs 2015;36:126–130.
    OpenUrl
  25. 25.↵
    1. Cho SH,
    2. Kim YS,
    3. Yeon KN,
    4. You SJ,
    5. Lee ID
    . Effects of increasing nurse staffing on missed nursing care. Int Nurs Rev 2015;62:267–274.
    OpenUrl
  26. 26.↵
    1. Blackman I,
    2. Henderson J,
    3. Willis E,
    4. et al
    . Factors influencing why nursing care is missed. J Clin Nurs 2015;24(1–2):47–56.
    OpenUrl
  27. 27.↵
    1. Grover A,
    2. Niecko-Najjum LM
    . Primary care teams: Are we there yet? Implications for workforce planning. Acad Med 2013;88:1827–1829.
    OpenUrl
  28. 28.↵
    1. Colwill JM,
    2. Cultice JM,
    3. Kruse RL
    . Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood) 2008;27:w232–w241.
    OpenUrlAbstract/FREE Full Text
  29. 29.↵
    Institute of Medicine. Living well with chronic illness: A call for public health action. 2012. Available from: http://iom.edu/Reports/2012/Living-Well-with-Chronic-Illness.aspx. Accessed February 1, 2017.
  30. 30.↵
    1. Schiff GD,
    2. Hasan O,
    3. Kim S,
    4. et al
    . Diagnostic error in medicine: Analysis of 583 physician-reported errors. Arch Intern Med 2009;169:1881–1887.
    OpenUrlCrossRefPubMedWeb of Science
  31. 31.↵
    1. Denzin NK,
    2. Lincoln YS
    . The SAGE Handbook of Qualitative Research. 3rd ed. Thousand Oaks, CA: Sage Publications Ltd.; 2005.
  32. 32.↵
    1. Kalisch BJ,
    2. Landstrom GL,
    3. Hinshaw AS
    . Missed nursing care: A concept analysis. J Adv Nurs 2009;65:1509–1517.
    OpenUrlCrossRefPubMedWeb of Science
  33. 33.↵
    1. Kinman KR,
    2. Gilchrist EC,
    3. Payne-Murphy JC,
    4. Miller BF
    . Provider- and practice-level competencies for integrated behavioral health in primary care: A literature review. Rockville, MD: Agency for Healthcare Research and Quality, 2015. Available from: https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcadLitReview.pdf. Accessed June 1, 2016.
  34. 34.↵
    1. Elder NC,
    2. Pallerla H,
    3. Regan S
    . What do family physicians consider an error? A comparison of definitions and physician perception. BMC Fam Pract 2006;7:73.
    OpenUrlCrossRefPubMed
  35. 35.↵
    1. Sandelowski M
    . Sample size in qualitative research. Res Nurs Health 2007;18:179–183.
    OpenUrl
  36. 36.↵
    1. Palinkas LA,
    2. Horwitz SM,
    3. Green CA,
    4. Wisdom JP,
    5. Duan N,
    6. Hoagwood K
    . Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health 2015;42:533–544.
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Speziale HJS,
    2. Carpenter DR
    . Qualitative research in nursing: Advancing the humanistic imperative. Philadelphia, PA: Lippincott; 2003.
  38. 38.↵
    1. Huberman AM,
    2. Miles MB
    1. Maxwell JA
    . Understanding and validity in qualitative research. In: Huberman AM, Miles MB, eds. The qualitative researcher’s companion. Thousands Oaks, CA: Sage Publications; 1992;37–64.
  39. 39.↵
    1. Dovey SM,
    2. Meyers DS,
    3. Phillips RL Jr.,
    4. et al
    . A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care 2002;11:233–238.
    OpenUrlAbstract/FREE Full Text
  40. 40.↵
    National Committee for Quality Assurance. Patient-centered medical home. 2014. Available from: http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed August 16, 2016.
  41. 41.↵
    The Joint Commission Accreditation Ambulatory Care. The Joint Commission primary care medical home (PCMH) Model. 2011. Available from: http://www.jointcommission.org/assets/1/18/joint_commission_pcmh_model.pdf. Accessed August 16, 2016.
  42. 42.↵
    American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA). Joint principles of the patient-centered medical home. 2010. Available from: http://practice.aap.org/content.aspx?aid=2063. Accessed May 17, 2016.
  43. 43.↵
    1. Weaver SJ,
    2. Lubomksi LH,
    3. Wilson RF,
    4. Pfoh ER,
    5. Martinez KA,
    6. Dy SM
    . Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med 2013;158(5 Pt 2):369–374.
    OpenUrlCrossRefPubMedWeb of Science
  44. 44.↵
    1. Verbakel NJ,
    2. Langelaan M,
    3. Verheij TJ,
    4. Wagner C,
    5. Zwart DL
    . Improving patient safety culture in primary care: A systematic review. J Patient Saf 2016;12:152–158.
    OpenUrl
  45. 45.↵
    1. Nemeth LS,
    2. Ornstein SM,
    3. Jenkins RG,
    4. Wessell AM,
    5. Nietert PJ
    . Implementing and evaluating electronic standing orders in primary care practice: A PPRNet study. J Am Board Fam Med 2012;25:594–604.
    OpenUrlAbstract/FREE Full Text
  46. 46.↵
    1. Zimmerman RK,
    2. Albert SM,
    3. Nowalk MP,
    4. Yonas MA,
    5. Ahmed F
    . Use of standing orders for adult influenza vaccination: A national survey of primary care physicians. Am J Prev Med 2011;40:144–148.
    OpenUrlCrossRefPubMed
  47. 47.↵
    1. Norful A,
    2. Martsolf G,
    3. de Jacq K,
    4. Poghosyan L
    . Utilization of registered nurses in primary care teams: A systematic review. Int J Nurs Stud. 2017;74:15–23.
    OpenUrl
  48. 48.↵
    Macy Foundation. Registered nurses: Partners in transforming primary care. 2016. Available from: http://macyfoundation.org/publications/publication/conference-summary-registered-nurses-partners-in-transforming-primary-care. Accessed January 16, 2017.
Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools

Jump to section

Keywords