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. 2007 Feb;53(2):271-6, 270.

Errors and adverse events in family medicine: developing and validating a Canadian taxonomy of errors

Sarah Jacobs  1 , Maeve O'Beirne, Luz Palacios Derfiingher, Lucie Vlach, Walter Rosser, Neil Drummond
Affiliations

Errors and adverse events in family medicine: developing and validating a Canadian taxonomy of errors

Sarah Jacobs et al. Can Fam Physician. 2007 Feb.

Abstract
in English, French

Objective: To develop a taxonomy of errors derived solely from the content of error reports using Canadian data from the Primary Care International Study of Medical Errors.

Design: Secondary analysis of data from a descriptive, cross-sectional, self-report survey.

Setting: Community-based family medicine clinics.

Participants: Family physicians.

Intervention: Implementation of an error-reporting system for family medicine.

Main outcome measures: Type of error, type of causal factor.

Results: Six types of errors or adverse events (administrative, communication, diagnostic, documentation, medication, and surgical or procedural) and 10 causal factors (case complexity, discontinuity of care, failure to follow protocol or accepted practice, fatigue, gap in knowledge, high workload, insufficient information on pharmacologic properties of medication, medication side effects, relationship dynamics, and structural problems) were identified.

Conclusion: Our taxonomy differs from that adopted by the Primary Care International Study of Medical Errors. We propose that our taxonomy is better suited for the purposes of family physicians reporting errors in Canada.

OBJECTIF: Élaborer une taxonomie des erreurs fondée uniquement sur les données canadiennes des rapports d’erreurs contenus dans la Primary Care International Study of Medical Errors.

TYPE D’ÉTUDE: Analyse secondaire des données d’une enquête transversale descriptive fondée sur des rapports par l’intéressé.

CONTEXTE: Cliniques de médecine familiale de milieu communautaire.

PARTICIPANTS: Médecins de famille.

INTERVENTION: Mise en place d’un système de rapports d’erreurs pour lesmédecins de famille.

PRINCIPAUX PARAMÈTRES ÉTUDIÉS: Types d’erreurs, types de facteurs en cause.

RÉSULTATS: On a identifié 6 types d’erreurs ou événements fâcheux (problèmes administratifs, de communication, de diagnostic, de documentation, de médication ou liés à des chirurgies ou techniques médicales) et 10 facteurs causaux (complexité des cas, défaut de continuité dans les soins, non-respect des protocoles ou des pratiques acceptées, fatigue, connaissances insuffisantes, forte charge de travail, manque d’information sur les propriétés pharmacologiques des médicaments et sur leurs effets indésirables, problèmes d’ordre relationnel et problèmes d’ordre structurel).

CONCLUSION: La taxonomie que nous proposons diffère de celle adoptée par la Primary Care International Study of Medical Errors. Elle nous paraît mieux convenir aux rapports d’erreurs produits par les médecins de famille canadiens.

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Comment in

  • Owning up to medical errors.
    Ladouceur R. Ladouceur R. Can Fam Physician. 2007 Feb;53(2):201. Can Fam Physician. 2007. PMID: 17872626 Free PMC article. No abstract available.
  • Thinking about errors.
    Bowes D. Bowes D. Can Fam Physician. 2007 Apr;53(4):626. Can Fam Physician. 2007. PMID: 17872709 Free PMC article. No abstract available.

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