Appendix 1

Appendix 1: Classification of Medical Errors and Patient Harm

Footnote:

*error definition: error determination adapted from several definitions.^1,2,3

† classification of error adapted from Kohn et al. ³

1. Grober ED, Bohnen JM. Defining medical error. Canadian Journal of Surgery 2005;48:39.

2. Agency for Healthcare Research (AHRQ). Understanding Medical Errors [internet]. Agency for Healthcare Research and Quality; 2013. (Accessed June 15, 2016, available at

http://archive.ahrq.gov/quic/report/mederr4.htm.)

3. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a Safer Health System: National Academies Press; 2000

Appendix 1 (continued): Classification of Medical Errors and Harm*

*adapted from Panesar, Sukhmeet Singh, et al. "How safe is primary care? A systematic review." BMJ Qual Saf (2015): bmjqs-2015.

Appendix 2: Apologies with implications for practice improvement

(*) Denotes events not present in contemporaneous review of Incident Report Logs A. IT and EHR related incidents

1. Inappropriate vaccine notifications sent to patients 2. Inappropriate notification sent for diabetic eye exam 3. Inappropriate mammogram notices *

4. Faxes for orders not being completed

5. Multiple instances of secure online messaging system not functioning appropriately 6. No standard location to keep record of outside colonoscopy *

7. Unable to flag inappropriate order at point of entry (inappropriate injection ordered) * 8. Secure online messaging communication not concordant with preference (listed

incorrectly as preferred communication method)

No potential to cause harm:

incident reviewed which was determined not to have the potential to cause any harm.

Example: Apology that patient was experiencing an outside stressor

No harm:

any patient safety incidents that have the potential to cause harm but was prevented, resulting in no harm, or that ran to completion but no harm occurred.

Examples: medication dosing error corrected before medication dispensed, delay in notification of normal test result

Low harm:

required extra observation or minor treatment and caused minimal harm Examples: patient repeated test which was incorrectly ordered, delayed access to care

Moderate harm:

resulted in a moderate increase in treatment and caused significant but not permanent harm (example would be hospitalization)

Example: avoidable emergency department visit as a result of a medical error

Severe harm:

resulted in permanent harm such as disability, death or long lasting physical or mental consequences

Example: ICU visit with resulting debility as a result of a medical error

B. Concerns related to medication prescribing

1. Medication not given in clinic leading to unnecessary ED visit * 2. Incorrect pharmacy chosen *

3. Prescription for incorrect frequency.

4. Patient out of catchment area asking for prescription *

5. Un-necessary face to face visit for controlled substance medication renewal C. Near miss events related to delay in communication

1. D-dimer ordered but no same day communication. * 2. Pap smear result incorrectly communicated as normal; * 3. Delay in informing patient of cancer diagnosis; *

4. Triage handoff: Urinalysis result not followed up on.

5. Follow up delay from Saturday clinic

D. Not fulfilling patient expectation: “tough love apology” and “out of scope”

1. Antimicrobial stewardship: apology for not giving antibiotics 2. Imaging stewardship: MRI not ordered *

3. Patient needs care out of primary care scope; mental health and complex pain needs*

4. Not able to complete disability forms *

5. Electronic visit dissatisfaction related to discordant patient expectations * E. Apology used to de-escalate a conversation

1. Apology to an irate patient. * F. Prophylactic or inconvenience apology

1. Will be unavailable for period of time (vacation) 2. Possibility of known drug side effect

3. Inconvenience associated with getting additional, appropriate blood test G. Professionalism/Patient sensitivity

1. Delivery of bad news over the phone. *

2. Concern regarding veracity of reason for delay- likely overstating technological limitations

i.e.- could use phone when secure online messaging not working H. Concerns related to test ordering, care coordination and follow-up

1. Test completed immediately and not in 6 weeks as intended resulting in unnecessary test *

2. Incorrect test ordered; appropriate repeat test required *

3. Multiple concerns about test results not being communicated from other departments*

4. Colon cancer screening results not sent to PCP *

5. Inadequate education prior to enrollment in coordinated behavioral health program * 6. Intake information incorrect- vaccination status , smoking status *

7. Tests and consults not being ordered at encounter completion

8. Pap smear report format leading to communication errors, HPV status *