BACKGROUND Despite recent attention given to medical errors, little is known about the kinds and importance of medical errors in primary care. The principal aims of this study were to develop patient-focused typologies of medical errors and harms in primary care settings and to discern which medical errors and harms seem to be the most important.METHODS Thirty-eight in-depth anonymous interviews of adults from rural, suburban, and urban locales in Virginia and Ohio were conducted to solicit stories of preventable problems with primary health care that led to physical or psychological harm. Transcriptions were analyzed to identify, name, and organize the stories of errors and harms.
RESULTSThe 38 narratives described 221 problematic incidents that predominantly involved breakdowns in the clinician-patient relationship (n = 82, 37%) and access to clinicians (n = 63, 29%). There were several reports of perceived racism. The incidents were linked to 170 reported harms, 70% of which were psychological, including anger, frustration, belittlement, and loss of relationship and trust in one's clinician. Physical harms accounted for 23% of the total and included pain, bruising, worsening medical condition, and adverse drug reactions.
DISCUSSIONThe errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities.
INTRODUCTION
T he report by the Institute of Medicine To Err is Human: Building a Safer Health System1 focused public attention on the problem of medical error. It also stimulated policy makers to devote new resources to characterize and prevent medical errors across the spectrum of health care. Much of the effort to date focuses on improving patient safety in hospitals, an appropriate priority given the suggested incidence of errors in inpatient settings, 2-4 the resulting anxiety engendered in the public sector, 5 and the opportunities for system redesign that can reduce the risk for errors and harms. 6 Yet most medical care occurs in ambulatory settings provided by primary care clinicians. 7,8 Published information about medical error in ambulatory primary care settings is limited. [9][10][11][12][13] It focuses on errors in diagnosis, treatment, and the delivery of preventive services and suggests that a cascade of information transfer problems is the proximal cause for many of these failures. 14 Although important, these studies have serious limitations, including varied defi nitions of error, reliance upon physician reports and perspectives, inconsistent taxonomies of errors and harms, and an absence of the causal analyses advocated by human factors experts.
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PATIENT REPORTS OF PREVENTABLE PROBLEMS AND HARMSBased on exis...
