Table 2 Descriptors of 590 testing process event reports submitted by family physicians and their office staffs
Reporting periodn (%)
Non-intensive370 (63)
Intensive*204 (35)
Don’t know16 (3)
No. of errors per event report
1302 (51)
2208 (36)
372 (12)
48 (1)
Error cascades†
Single error302 (51)
More than one error
    Independent errors29 (5)
    Cascade of errors231 (39)
    Cascade and independent errors28 (5)
Place of occurrence
Offsite117 (20)
Onsite360 (61)
Both79 (13)
Unknown34 (6)
Specific location of the error(s)‡
Reporter’s office412 (60)
Nursing home6 (1)
Hospital39 (6)
Emergency department4 (1)
Onsite lab54 (8)
Offsite lab126 (18)
Radiology30 (4)
Other site (eg, home, other office)11 (2)
Estimated frequency of occurrence in this practice
This is the first time it has occurred60 (10)
Seldom (once or twice per year)111 (19)
Sometimes (three to 11 times per year)209 (35)
Frequently (more than once per month)204 (35)
Not reported6 (1)
Not very serious97 (16)
Somewhat serious216 (37)
Serious143 (24)
Very serious89 (15)
Extremely serious39 (7)
Not reported6 (1)
Actions taken as a result of the error‡
No intervention/activity specific to event71 (12)
Medical attention or intervention117 (19)
Other intervention298 (48)
Unable to determine121 (20)
System, protocol, or practice change8 (1)
  • *During intensive reporting periods, participants were instructed to report every error in the testing process that they observed. Intensive reporting occurred for four of the 32 reporting weeks for each practice at staggered intervals.

  • †An error “cascade” was noted if there was a clear causal connection between at least two of the errors reported in an event report; if a report included three or four errors, the report might include an error cascade and an independent error.

  • ‡Totals to more than 590 because multiple locations/actions taken were reported in some event reports.