Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network D G Graham, 1 D M Harris, 2 N C Elder, 3 C B Emsermann, 4 E Brandt, 1 E W Staton, 4 J Hickner 5 1 American Academy of Family Physicians, National Research Network, Leawood, Kansas, USA; 2 CNA Corporation, Alexandria, Virginia, USA; 3 Department of Family Medicine, University of Cincinnati, Cincinnati, Ohio, USA; 4 Department of Family Medicine, University of Colorado at Denver and Health Sciences Center, Aurora, Colorado, USA; 5 Department of Family Medicine, University of Chicago, Chicago, Illinois, USA Correspondence to: D Graham, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211, USA; dgraham@aafp.org Accepted 8 February 2008 ABSTRACT Objectives: Little research has focused on preventing harm from errors that occur in primary care. We studied mitigation of patient harm by analysing error reports from family physicians’ offices. Methods: The data for this analysis come from reports of testing process errors identified by family physicians and their office staff in eight practices in the American Academy of Family Physicians National Research Network. We determined how often reported error events were mitigated, described factors related to mitigation and assessed the effect of mitigation on the outcome of error events. Results: We identified mitigation in 123 (21%) of 597 testing process event reports. Of the identified mitigators, 79% were persons from inside the practice, and 7% were patients or patient’s family. Older age was the only patient demographic attribute associated with increased likelihood of mitigation occurring (unadjusted OR 18– 44 years compared with 65 years of age or older = 0.27; p = 0.007). Events that included testing implementation errors (11% of the events) had lower odds of mitigation (unadjusted OR = 0.40; p = 0.001), and events contain- ing reporting errors (26% of the events) had higher odds of mitigation (unadjusted OR = 1.63; p = 0.021). As the number of errors reported in an event increased, the odds of that event being mitigated decreased (unadjusted OR = 0.58; p = 0.001). Multivariate logistic regression showed that an event had higher odds of being mitigated if it included an ordering error or if the patient was 65 years of age or older, and lower odds of being mitigated if the patient was between age 18 and 44, or if the event included an implementation error or involved more than one error. Mitigated events had lower odds of patient harm (unadjusted OR = 0.16; p,0.0001) and negative consequences (unadjusted OR = 0.28; p,0.0001). Mitigated events resulted in less severe and fewer detrimental outcomes compared with non-miti- gated events. Conclusion: Nearly a quarter of testing process errors reported by family physicians and their staff had evidence of mitigation, and mitigated errors resulted in less frequent and less serious harm to patients. Vigilance throughout the testing process is likely to detect and correct errors, thereby preventing or reducing harm. Most patient safety studies in primary care settings have been descriptive, and those studies have led to a better understanding of the types of errors occurring in those setting, their consequences, and potential remedies. 1–13 However, little research in primary care has focused on activities that occur during an error event chain to prevent or minimise harm, which is called mitigation. 7 13 14 The use of the term ‘‘mitigation’’ is not consistent in the patient safety literature; conse- quently, it is necessary for us to further specify our use of the term. We see mitigation taking place in what Van der Schaaf 15 describes as the ‘‘dangerous situation’’—the temporary state that follows the occurrence of a human error or system failure, before it resolves into its outcome. We distinguish it from ‘‘recovery,’’ which is the action of people or systems that takes place after the chain of events has played out. Nolan specifies three strategies for the design of safe healthcare systems: preventing errors, making errors visible, and mitigating the effects of errors. 16 His ‘‘mitiga- tion’’ closely resembles our term ‘‘recovery,’’ whereas his ‘‘making errors visible’’—which he refers to as ‘‘procedures or attributes that make errors visible to those working in the system so that they can be corrected before causing harm’’— is part of our mitigation process. Our ‘‘mitigation’’ takes place when an error becomes visible (in our terminology, ‘‘discovered’’) and an intentional action is undertaken to avoid or reduce harm. Helmreich’s three-tiered pyramid model of error management 17 distinguishes between avoiding errors, trapping those errors that are not avoided (our ‘‘mitigation’’), and mitigating those errors that are not trapped (our ‘‘recovery’’). If we draw an analogy to prevention, stopping an error from occurring is primary prevention, mitigation is secondary prevention, and recovery is tertiary prevention. While some errors result in harm (preventable adverse events), others do not (close calls or near misses). Some errors do not cause harm by chance or because the errors are remote from patients, but others do not cause harm because humans or systems catch the errors and prevent or mitigate patient harm. A few researchers have investigated near misses, recovery from near misses, and mitigating behaviour in disciplines other than primary care. 15 18–22 An error frequently entails a chain of events that go wrong. 23 Interceding somewhere in the chain of events can prevent additional errors from occur- ring, stop them from reaching or harming patients, or reduce the amount of harm experienced. Such Error management Qual Saf Health Care 2008;17:201–208. doi:10.1136/qshc.2007.022566 201