AHRQ Patient Safety and Quality
The aim of this project is to conduct large scale beta testing of the AHRQ Medical Office Survey on Patient Safety (SOPS), which was designed to assess the safety culture of primary and specialty care settings. The Oregon Rural Practice-based Research Network (ORPRN) has developed a consortium of 14 practice-based research networks (PBRN) with practices located in 18 states in the U.S. to conduct the SOPS with a combined strength of 300 clinics and their providers and staff. The consortium assembled for this study offers 1,311 primary care practices in 18 states representing a wide range of practice characteristics. Expected outcomes of this test include developing a comparative benchmarking database for future users of the SOPS, and understanding the barriers encountered in completing the survey and clinic perceptions of the value of the survey data for their quality improvement initiatives.
CCPC will:
- Provide data on network characteristics
- Recruit 25 practices
- Orient practices to SOPS survey
- Administer surveys to all staff in the recruited practices
- Administer follow-up survey on ease of completion and usefulness of SOPS
- Participate in multi-PBRN coordination of project.
Past Projects
MEADERS: Medication Errors and Adverse Drug Event Reporting System For Ambulatory Care
CCPC recruited nine ProHealth Physicians practice sites to participate in a national Medication Errors and Adverse Drug Event Reporting System for Ambulatory Care (MEADERS) pilot. The pilot was sponsored by the national Agency for Healthcare Research and Quality (AHRQ) and Indiana University to test a user-friendly primary care medication event reporting system that can be used for quality improvement at the practice level and for adverse drug event surveillance at the national level by contributing data to the FDA’s MedWatch program. Practices were asked to complete a simple, secure online event form to report medication errors or adverse drug events as they occur for a period of 10 weeks. When a clinician or staff member completed a medication error or adverse event report, he or she had the option of sending the report to the FDA’s MedWatch database. At the conclusion of the pilot period, providers and their office managers were also asked to complete a survey regarding their experiences using the MEADERS program.
Medication Errors in Family Medicine Practice
Office processes are significant sources of medication errors in primary care settings. The research team quantitatively described medication transaction activity in family medicine practices to determine the rate of medication related errors, and the process associated with medication error. The primary outcome measure was medication related errors categorized according to the International Taxonomy of Errors in Primary Care.
Three family practice offices (14 physicians, 18 staff) recorded interactions concerning medications during a two hour period on two different days. Each person handling a medication transaction documented their involvement and flagged potential errors. A study coordinator abstracted additional information from the patient charts. Two principal investigators reviewed each transaction to determine if the transaction involved an error.
Results: Practice staff recorded 247 medication transactions including 98 for office visits, 70 patient refill requests, 34 pharmacy refill requests, 16 non-visit patient questions, 13 initiated by laboratory results, 7 pharmacy benefit issues, and 9 other. Gap analysis identified 31 documentation errors during patient encounters and 35 documentation errors occurring during post-visit contacts. Transaction logs identified 18 errors discovered at subsequent post visit contact initiated by prior error. Errors flagged on 84 (34%) of the transactions included: 59 not listed on the chronic medication sheet, 7 not listed in chart, 6 wrong dose prescribed, 5 incorrectly written, 3 for failure to implement medication across care settings, 1 contraindicated medication, 1 wrong patient chart, and 2 other. Of the transactions, 31 involved a new chronic medication (74.2% error), 135 existing chronic medications (37% error), and 80 acute episodic medication (13.8% error). Two or more medications were involved in 66 transactions (45.5% error). The 18 non documentation errors all involved additional workflow: visits, phone calls, faxes to rectify the discovered errors.