Patient Reports of Preventable Problems and Harms in Primary Health Care

Abstract

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. 334 PATIENT REPORTS OF PREVENTABLE PROBLEMS AND HARMSBased on exis...

Patients’ and relatives’ complaints about encounters and communication in health care: Evidence for quality improvement

“…Physicians with no-claim seemed to conduct longer visits, educate patients more, check understanding more and use more humour during the visit than physicians with claims [9]. A study by Kuzel [10] showed that negative outcomes in the clinician-patient relationship, dominated by stories of disrespect or insensitivity, were reported as more common than technical errors in diagnosis and treatment.…”

“…Physicians with no-claim seemed to conduct longer visits, educate patients more, check understanding more and use more humour during the visit than physicians with claims [9]. A study by Kuzel [10] showed that negative outcomes in the clinician-patient relationship, dominated by stories of disrespect or insensitivity, were reported as more common than technical errors in diagnosis and treatment.The Institute for Healthcare Improvement (IHI) emphasizes that the health care system needs to be more patient-centred and to involve the patients and families in the design of care. Patient-centred care requires respect for patients' values and expressed needs, information and communication, coordination of care, involvement of family, 4 and concordance between the patient and health professionals [11].…”

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events

“…4 See Hibbard, Peters, Slovic, and Tusler M., 2005;Blendon, DesRoches, Brodie, et al, 2002;Marella, Finley, Thomas, and Clarke, 2007;Schwappach, 2010;Schwappach and Wernli, 2010; The Kaiser Family Foundation/Agency for Healthcare Research and Quality, 2008;Waterman, Gallagher, Garbutt, Waterman, Fraser, and Burroughs, 2006. 5 See Basch, Artz, Dulko, et al, 2005;Kuzel, Woolf, Gilchrist, et al, 2004;Weingart, Gandhi, Seger, et al, 2005;Weingart, Pagovich, Sand, et al, 2005;Weingart, Pagovich, Sands, et al, 2006;Weingart, Price, Duncombe, et al, 2007;Zhu, Stuver, Epstein, Schneider, Weissman, and Weingart, 2011. 6 See Agoritsas, Bovier, and Perneger, 2005;Blenkinsopp, Wilkie, Wang, and Routledge, 2007;Friedman, Provan, Moore, and Hanneman, 2008. These researchers succeeded in eliciting patient safety reports through patient interviews; however, patient reports frequently require recoding or classification to enable the extraction of the key content, resolve discrepancies or inconsistencies, and assess the attribution of symptoms or complications to care rather than to the natural history of disease.…”

Disclosing Medical Mistakes: A Communication Management Plan for Physicians

“…Two tasks help develop mistake disclosure strategies: 1) the context of disclosure delivery and 2) the content of mistake messages, sequencing, and apology. 5,[33][34][35] …”