An international taxonomy for errors in general practice: a pilot study

Meredith A B Makeham, Mary County, Michael R Kidd and Susan M Dovey
Med J Aust 2002; 177 (2): 68-72. || doi: 10.5694/j.1326-5377.2002.tb04668.x
Published online: 15 July 2002


Objectives: To develop an international taxonomy describing errors reported by general practitioners in Australia and five other countries.

Design and setting: GPs in Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States reported errors in an observational pilot study. Anonymous reports were electronically transferred to a central database. Data were analysed by Australian and international investigators.

Participants: Non-randomly selected GPs: 23 in Australia, and between 8 and 20 in the other participating countries.

Main outcome measures: Error categories, and consequences.

Results: In Australia, 17 doctors reported 134 errors, compared with 301 reports by 63 doctors in the other five countries. The final taxonomy was a five-level system encompassing 171 error types. The first-level classification was "process errors" and "knowledge and skills errors". The proportion of errors in each of these primary groups was similar in Australia (79% process; 21% knowledge and skills) and the other countries (80% process; 20% knowledge and skills). Patient harm was reported in 32% of reports from Australia and 30% from other countries. Participants considered the harm "very serious" in 9% of Australian reports and 3% of other countries' reports.

Conclusions: This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.


The Robert Graham Center of the American Academy of Family Physicians invited investigators from Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States to participate in PCISME. Countries were chosen because they had a similar concept of primary healthcare and their healthcare systems all delivered a First World style of medicine.

In essence, PCISME was a survey of the errors noted by a non-random sample of GPs in the six participating countries. All participants were allowed a minimum of three months to contribute reports. Data collection occurred from June to October 2001 in Australia, and in other countries between June and December 2001.

The protocol was approved by the University of Sydney Human Research Ethics Committee.

Reporting process

Error reports could be completed on any computer with an Internet connection. The World Health Network's medical information software "Healix" was used to access the study's electronic reporting form and to transmit data. Each report was identified with a self-chosen personal identification number (PIN). Doctors indicated their country, and then proceeded through the questionnaire (Box 1). They were asked not to use any identifying information in their reports.

High-level encryption was used when transmitting the data to the server in London, UK. Doctors were advised not to disclose their PIN, and not to retain paper copies of their error reports. The PINs were not known by the researchers, and were used solely to identify how many reports a participant had contributed. Access to the database was limited to the chief investigators in each country.


As the reports were submitted, the Australian investigators, in consultation with the International Principal Investigator, categorised them. Error reports from the other participating countries were simultaneously categorised in this manner. The taxonomy was initially based on an earlier US pilot study.1 It was further developed and refined during the trial in order to capture the full extent of error types reported from all countries.

The proportion of reports attributable to each category was calculated for Australia and for all other countries combined.


The principal findings of the PCISME pilot study support the theory that general practice in Australia shares many of the types of problems encountered by GPs in other, similar developed countries. This is demonstrated by the taxonomic descriptions at the second order of classification: all categories of errors that occurred in Australia occurred in one or more of the other countries. We have also been able to demonstrate a successful method of electronically reporting mistakes in an Australian general practice setting.

Our aim has been to try to capture the breadth of different mistakes occurring. The design of the study did not allow quantification of the prevalence of different error types. The limitation with all research of this nature is that a doctor must be aware that an error has occurred, and then must be willing to report the error.

It is possible that the payment of the Australian doctors contributed to the greater numbers of reports from this group. Previous primary care research has suggested that recruitment and quality might be improved through payments,5 and that, for research that is otherwise ethically permissible, it is also ethically permissible for researchers to pay participants for their out-of-pocket expenses, participation, inconvenience and risk-taking.6 Primary care funding varies significantly among the participating countries, and other countries chose not to offer an honorarium.

A high level of computer literacy was required to participate in PCISME, and this might have affected the types of errors that were described. All error reports were submitted electronically from participating countries, except for Canada, where software problems resulted in their doctors mainly reverting to paper reports. In Australia, there is a high level of computer use in general practice, with around 89% of practices now using computers.3

In relation to other studies, PCISME built upon earlier patient safety research conducted in Australia, and extended it into an international context. Australia has been a leader in carrying patient safety research into primary care settings. In 1993, the Commonwealth Government provided funding to test incident monitoring in six specialties, including general practice. A pilot incident-monitoring study was conducted by the RACGP and the Family Medicine Research Unit of the University of Sydney. An analysis of the first 805 incidents reported by GPs between October 1993 and June 1995 demonstrated that incident monitoring can be successfully applied in general practice,7,8 and is useful for identifying sources of misdiagnosis and for implementation and assessment of quality improvement strategies.9

PCISME differs from previous Australian work with respect to the methodology of error reporting and the classification system used to describe these errors. As the two studies used non-random samples of Australian GPs taken from different study populations, there is limited comparability between the results of PCISME and the earlier incident-monitoring study.7,8,10 Furthermore, PCISME used a different definition of error from previous Australian studies, which defined an incident as "an unintended event, no matter how seemingly trivial or commonplace, that could have harmed or did harm a patient".7 The definition of error used in our study was broader, being concerned with mistakes rather than patient harm, and so could have encouraged more reports that posed less threat to patient safety, such as administrative problems. The definition we used was generally well understood by PCISME participants, with only six reports from all countries (1.4%) assessed as not involving an error.

Doctors and other healthcare professionals have been reluctant to admit and address the problem of errors, both because of feelings of guilt and from the desire to avoid colleagues' disapproval or punishment.11,12 Studies of this nature might increase the acceptability of discussing mistakes in general practice.

Our study has commenced the development of an international taxonomy of errors in primary care which can be used to plan future studies examining the prevalence of mistakes in general practice. The strength of an international collaboration will become apparent when meaningful differences between countries are defined in the prevalence of different error types. This information can then be used to design interventions or alter existing systems to reduce errors in primary care.

4: The first three levels of the five-level taxonomy of errors, with number (%) of reports in the first two levels


Other countries

1. Process Errors

104 (79%)

236 (79%)

1.1. Errors in office administration

26 (20%)

55 (19%)

1.1.1. Filing system errors

1.1.2. Chart completeness errors

1.1.3. Patient flow (through the healthcare system)

1.1.4. Message handling errors

1.1.5. Appointments errors

1.1.6. Errors in maintenance of a safe physical environment

1.2. Investigation errors

17 (13%)

55 (19%)

1.2.1. Laboratory errors

1.2.2. Diagnostic imaging errors

1.2.3. Errors in the processes of other investigations

1.3. Treatment errors

38 (29%)

72 (24%)

1.3.1. Medication errors

1.3.2. Errors in other treatments

1.4. Communication errors

20 (15%)

42 (14%)

1.4.1. Errors in communication with patients

1.4.2. Errors in communication with other healthcare providers (non-medical)

1.4.3. Errors in communication with other doctors

1.4.4. Errors in communication amongst the whole healthcare team

1.5. Payment errors

1 (1%)

4 (1%)

1.5.1. Errors in processing insurance claims

1.5.2. Errors in electronic payments

1.5.3. Wrongly charged for care not received

1.6. Errors in healthcare workforce management

2 (2%)

8 (3%)

1.6.1. Absent staff not covered

1.6.2. Dysfunctional referral procedures

1.6.3. Errors in appointing after-hours workforce

2. Knowledge and Skills Errors

28 (21%)

61 (21%)

2.1. Errors in the execution of a clinical task

7 (5%)

7 (2%)

2.1.1. Non-clinical staff made the wrong clinical decision

2.1.2. Failed to follow standard practice

2.1.3. Lacked needed experience or expertise in a clinical task

2.2. Errors in diagnosis

18 (14%)

36 (12%)

2.2.1. Error in diagnosis by a nurse

2.2.2. Delay in diagnosis

2.2.3. Wrong or delayed diagnosis attributable to misinterpretation of investigations

2.2.4. Wrong or delayed diagnosis attributable to misinterpretation of examination

2.2.5. Wrong diagnosis by a pharmacist

2.2.6. Wrong diagnosis by a hospital-based doctor

2.3. Wrong treatment decision with right diagnosis

3 (2%)

18 (6%)

2.3.1. Wrong treatment decision, influenced by patient preferences

2.3.2. Wrong treatment decision by doctor

Received 19 April 2002, accepted 3 June 2002

  • Meredith A B Makeham1
  • Mary County2
  • Michael R Kidd3
  • Susan M Dovey4

  • 1 Department of General Practice, University of Sydney, Sydney, NSW.
  • 2 The Robert Graham Center: Policy Studies in Family Practice and Primary Care, American Academy of Family Physicians, Washington, DC, USA.



We gratefully acknowledge the GP participants from the six countries. We would like to thank Walter Rosser, Aneez Esmail, Katherine Hall, Chris Van Weel, Anton Kuzel, Steven Woolf, and the other research members of the LINNAEUS collaboration. We also thank the World Health Network, Professor Charles Bridges-Webb AO of the NSW Projects, Research and Development Unit, RACGP, and Dr Jonathon Craig, Department of Public Health, University of Sydney, for their assistance.

Competing interests:

None identified.

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