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

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Abstract
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 (pConclusions: 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.