ASIPS Logo - working together to improve health: Applied Strategies for Patient Safety

Summary of ASIPS Study

Purpose: Applied Strategies for Improving Patient Safety (ASIPS) was a collaborative effort between the University of Colorado Department of Family Medicine and numerous organizations to analyze the causes and effects of errors in primary care and reduce the incidence of errors. ASIPS collected reports of errors or incidents through the Patient Safety Reporting System, a voluntary incident reporting system. The system offered three different ways to confidentially or anonymously report an error: via web site, telephone hotline, or paper.

In addition to the primary data obtained from the Patient Safety Reporting System, ASIPS researchers analyzed secondary data provided by collaborating Colorado organizations. Using these secondary data, ASIPS researchers assessed the specific incidents and trends that may or may not be reported to the CU DFM, as well as trends occurring in larger populations of practices. Based on the understanding of primary care errors that evolved from both data analyses, ASIPS developed and implemented interventions aimed at decreasing recognized errors in primary care. The interventions were developed by clinicians and staff from practices, with guidance from ASIPS partners, including two insurance organizations, the State Department of Health and the Colorado Hospital Association.

The setting for ASIPS was a combination of two practice-based research networks, the Colorado Research Network (CaReNet), which focuses on rural and urban minority and underserved primary care populations, and the High Plains Research Network (HPRN), which focuses on rural, "frontier" primary care practices and hospitals.

Activities centered around reinforcing use of the reporting system, securing the secondary data, refining the data collection system, and analyzing primary data as it becomes available. Also, a clinical steering committee was convened to finalize the analysis plan and monitor the usefulness of the coding taxonomy for the incidents reported. Learning groups of physicians and key office personnel were assembled to review errors collected and plan interventions. Three interventions were implemented.

Specific Aims of the Proposed Project were:

Enhance the efforts of the CU DFM and the clinical sites to collect medical error data by assessing the ability of a newly created incident reporting system to collect meaningful information.
Assess attitudes among clinicians and staff toward the data collection system.
Compile and compare shared data from Colorado organizations concerned with patient safety.
Develop a multidimensional approach to medical error analysis that will result in an improved understanding of medical errors and their root causes.
Develop and evaluate a system to inform patients about selected errors in collaboration with the University of Colorado Health Sciences Center Trust (HSC Trust).
Reduce the number of medical errors and near misses in our clinical sites.
We anticipate that at the end of the three-year funding period, ASIPS will become a resource in the Rocky Mountain area and beyond for implementing a proven error reduction strategy that is appropriate for a variety of settings.