In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith finds an unsigned abnormal Papanicolaou test result from 18 months ago. *

A patient is instructed to take his medication three times a day after meals. The patient returns to the physician office reporting that there has been no change in his condition. The doctor examines the patients medication bottle and finds 1/3 of the supply still in the bottle. When asked why he did not take the medication, the patient responded that he only eats twice a day.*

John is a 50 year old male whose parents were recently diagnosed with colon cancer.  He visits his physician complaining of knee pain. The doctor, usually diligent in updating a patient’s  family history, is distracted and does not do so. John, now considered to be in a high risk group, does not realize he should be screened.*

These examples of system defects that lead to harm may be familiar to you either as a patient or provider of care. Unreliable and poorly designed processes in office and ambulatory care settings can lead to errors in prescribing, diagnosis, follow-up on test results, and many other problems.  There are proven, fundamental patient safety principles that can be applied to any practice to improve patient outcomes. 

The Institute for Healthcare Improvement (IHI) has developed a new Web&ACTION program called Improving Safety and Reliability in the Physician Office. This web-based program is specifically designed to give you the opportunity to examine system defects, understand why errors occur, and make your processes more reliable through practical teaching and tools from expert faculty. You will learn how to use methods and high-level flow diagrams to identify sources of error and harm, and then use rapid cycle testing to begin to reduce them during the course of the five web-based sessions. The faculty will present you with principles to get started, as well as coaching and guidance throughout the program to help you develop a safe and reliable office practice. 

Upon completion of this program, participants will be able to:

• Describe methods to identify unreliable processes in the office setting
• Describe methods to identify errors and harm patients may experience in office-based care
• Discuss two methods to improve processes to minimize the opportunity for error and harm in your setting

*Cases come from AHRQ's Web M&M