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

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 practicelevel 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.