Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients

Alden Yuanhong Lai, PhD; Christina T. Yuan, PhD; Jill A. Marsteller, PhD; Susan M. Hannum, PhD; Elyse C. Lasser, MS; JaAlah-Ai Heughan, MS; Tyler Oberlander, BA; Zackary D. Berger, MD; Ayse P. Gurses, PhD; Hadi Kharrazi, MD, PhD; Samantha I. Pitts, MD; Sarah H. Scholle, PhD; Sydney M. Dy, MD

Disclosures

J Am Board Fam Med. 2020;33(5):754-764. 

In This Article

Results

The interview participants comprised 37 administrators, 25 physicians, 11 medical assistants, 9 care coordinators/navigators, 8 nurses, and 11 others (dental staff, pharmacists, social workers, and physician assistants) who had worked for a mean of 6 years in their practice. Most of the patient focus group participants were female (53.8%), white (84.6%), between the ages of 46 to 65 (33.8%), and had a college degree/completed some college (47.7%). The PCMH practices included in our sample fully reflected the purposive sampling frame we adopted: 5 of the practices were hospital/health system owned, 4 were independent clinician owned, and 1 was a federally qualified health center. Six of the practices were located in suburban areas, 3 were in rural areas, and 1 was in an urban area. See Table 1 and Table 2 for other participant characteristics.

We identified 5 main themes in the form of "work functions" related to how personnel and patients conceptualized the meaning of patient safety in primary care. We defined work functions as the tasks or perceived responsibilities that are grouped in particular ways to guide how work is being done. Furthermore, the theme names were grounded in the participants' own expressions of their conceptualizations. They include (1) not causing harm, (2) viewing patients' needs holistically, (3) providing appropriate and timely care, (4) ensuring physical safety and informational security, and (5) communicating attentively. The second theme contains 1 subtheme: (2a) considering social determinants of health (SDOH); and the third theme contains 2 subthemes: (3a) coordinating care and (3b) shared decision-making. Overall, personnel and patients conceptualized patient safety in primary care in largely consistent ways, with some areas of divergence that are described below.

We detail the results in the following order. First, we elaborate 4 of the 5 themes that emerged from the inductive coding of personnel interview data. We present these themes in conjunction with the convergence assessment against patient data to highlight areas of agreement, partial agreement, dissonance, or nonnarration. Second, we present results on the final theme that emerged from the inductive coding of the patient focus group data, which was not highlighted in the personnel interviews. See Appendix for a tabular presentation of the results.

Elaboration of Themes and Degree of Convergence

Patient Safety as not Causing Harm. Personnel conceptualized patient safety as not causing harm to patients when providing care, with emphasis on the effects of medications and procedures and how they could potentially impact patients:

"I take that Hippocratic Oath of 'do no harm' very seriously. Every kind of prescription I give, every decision I'm going to make, I always think, am I doing more harm than good, so that's sort of my mantra." –physician, identifier [ID] 55, site 6

There was agreement on this theme with how patients conceptualized safety. Patients recognized the importance of having their health care providers pay attention to their medications in particular, due to similar concerns about potential adverse effects.

"They [the practice] always keep up with your medicine. That's just very important to me. Especially being diabetic. Because some of those medicines just will not, they just don't agree with me. And it's scary when your blood sugar drops and you're just in a pickle." –patient C, site 9

However, as personnel highlighted nonmaleficence as part of patient safety, a consideration surfaced when they also acknowledged that medical treatments will always pose some risk of harm to patients. To address this, they described efforts to (1) select medical interventions that balanced minimal risks with maximal benefits and (2) ensure that medical procedures were error free:

"[H]arm is unavoidable. The nature of the way we practice medicine…there is no drug that comes without adverse effects. I tell my patients, every time we start with a new med, there is no drug that you will take that will not have some complications. There is a sort of unavoidable nature, but I think our job is to pay attention and to try to minimize the complications to the extent that they are minimizable." –physician, ID 82, site 8
"Safe medical care is doing our due diligence…eliminating opportunities for error through systematic ways and accounting for the fact that we know that we don't know everything, so to the best knowledge, kind of giving 110 percent each time to make sure that there are no opportunities for errors, but to also be able to adapt to those opportunities when they come." –pharmacist, ID 70, site 7

Patient Safety as Viewing Patients' Needs Holistically. Personnel viewed patient safety as considering patient needs from various aspects, which included primary and specialist care needs, mental health needs, dental health needs, and the needs that patients have when they are at home or traveling. A physician detailed this view when assessing risks to patients' health to identify those that were relevant to safety:

"Patient safety to me, runs a gamut of a whole spectrum of things. It begins in the entire realm of medical care starting in regards to the patient at their home and evaluating that through the entire continuum of medical care, whether it's here at the office, our urgent care centers, our hospital, or any other medical facility. And then, try to evaluate the patient in regards to where are those risks? To the patient's wellbeing? To their health? To their chronic medical illnesses, etcetera. It exists in multiple different areas of the patient's life." –physician, ID 38, site 4

Patients showed agreement with this view of patient safety. They emphasized the need for health care providers to "look at the whole picture and know the right questions to ask" (–patient A, site 2). A patient positively recalled her physician delving into the life events that might have contributed to hypertension instead of suggesting a drug intervention immediately:

"I think what I've found is that my doctor looks at all of me. Patient A has high blood pressure, oh she's anxious. No. Looking at the whole big picture…what's going on in life? What has made you anxious? So not just pinpointing, oh here's a medication for that. [The doctor is] looking at all of me and I like that. I like that feeling." –patient A, site 1

Considering SDOH: In keeping with the holistic needs of each patient, personnel highlighted the importance of patients' SDOH and access to health and social services. Personnel reflected these concerns as well as efforts to address them:

"Social determinants when they [patients] come in, thinking about those types of things, like, do they have insurance? Do they have a job? Do they have ways of paying for medications? Especially chronic diseases…because sometimes they'll come in and they don't have the money to pay for medications and that's not safe for them if they can't take their medicine, so we try to help them as best as we can." –practice manager, ID 82, site 9

Patients, however, did not highlight their personal and socioeconomic situations as part of safety. This subtheme was therefore classified as nonnarrated among patients.

Patient Safety as Providing Appropriate and Timely Care. Personnel also emphasized delivering care that was "right," elaborated in terms of appropriateness and timeliness. They conceptualized this in terms of treatment plans and time in which treatment was provided:

"First, do no harm. But, in a broader sense, it is the right care for the right patient at the right time. It means understanding the patient, their situation in a timely way, which would involve recognition of issues in a timely way, and then direction into the right treatment pathways." –physician, ID 65, site 7

From the patient perspective, there was agreement for this theme. There was an expectation of having their clinical conditions addressed with appropriateness and timeliness when receiving primary health care:

"When you come here and see a doctor or PA [physician assistant] for medical advice and care, it's care that's going to take care of you. And in fact, what you're coming in with is going to be dealt with. If they can't cure it, at least they can tell you what it is and maybe start you on a program to handle that. It doesn't get worse and they don't misdiagnose. I'd say those are the two things that would make me wonder if it's safe." –patient A, site 3

Coordinating Care: A subtheme emerged when personnel specifically highlighted the role of care coordination for patients as a key aspect of safety. They described the responsibilities of facilitating, from the beginning to end, and in a timely way, the required follow-up tests, procedures, and specialist referrals for patients:

"If their safety is they need a CAT [computerized axial tomography] scan, we have to make sure it's going to get done and get it done in a timely manner and make sure that if anything has to happen after that, if they need to see a surgeon or whatever, that's safety because we're seeing the patient from beginning to end and make sure that, again, that loop is completed…And the other thing, too, is following through with referrals, appointments to a specialist and tests, and things that the doctors order at the time of the visit. So, we do a loop with ordering it, scheduling it, following through, and we get the report." –administrator, ID 39, site 4

This subtheme was however only in partial agreement against patients' conceptualization of safety. Personnel focused on the activities they were performing for care coordination, whereas patients instead focused on the trust they placed in their own primary care providers and that their medical needs would be met appropriately and timely as well when being referred to other providers. Patients therefore affiliated an element of trust with patient safety in the care coordination process:

"You rely more on your primary care physician to direct you to the specialties and I think hopefully you have trust in them enough that they are directing you to the proper specialty because I think that concerns me as far as safety because I don't know who's out there, so I have to rely on her to tell me now okay, we're going to set up an appointment for you with Dr. so-and-so to look at whatever. So, how are we to know with the professional we're now going to. We're leaving our primary care physician, who we liked very much, is directing us to the right specialty." –patient E, site 4

Shared Decision-making: Personnel also perceived patient safety as the inclusion of the patient as a partner when deciding on medical treatments and managing their health:

"[Patient safety is] care where we get the best outcome for the patient…get the patient involved…I've always had my philosophy that the patient needs to be involved. And my role is a consultant and teaching the patient as much as possible as to what's going on. Patient safety is that the patient is aware of it, knows why we're doing it, is on board with doing whatever the intervention is and complies with it and hopefully gets the good results." –physician, ID 17, site 2

There was agreement on this notion of shared decision-making from the patient point of view. Patients described that safe care was when they were able to comprehend the diagnosis, proposed treatment, and potential risks for their condition. These entailed being an active participant of the medical decision making process:

"Ensuring that the patient understands what's going on, why you're doing it, what the risks are, what the complications may be, and involving the patient in involving the patient in their own treatment so that they understand the importance of what has to be done and why they should do it and to me, that's safety. That's important safe medical care." –patient C, site 2

Patient Safety as Ensuring Physical Safety and Informational Security. The concept of patient safety also extended to the infrastructure of the practice environment. Personnel emphasized patient safety in this realm in 2 ways, which were in agreement with patients' views. The first was ensuring that patients, especially older adults, were free from fall risks during visits. Safety was about the ease with which patients can physically navigate around the clinic and that equipment was available for use to mitigate fall risks.

"So safe medical care means to me that when the patient comes in, they can safely get to the chair, they can safely room, go to the bathroom by themselves…their stability and their balance and everything are intact where they're not falling. Very simple. Well, there are bars in the bathroom for the patient to make sure that they can sit properly if they are handicapped and there's no steps. There's a ramp and there's the doors that open automatically, which we use. Probably what I would assess here at the practice being patient safety is that we have the bars and we have the equipment." –medical assistant, ID 58, site 6

Patients similarly echoed considerations for the ease of arriving at the clinic and physical safety:

"I'm ambulatory, but I do walk with a cane. So, to me it starts before I get into the office. Is there snow removal, ice, handicap parking, can I even make it to the door…I've been to specialist's office in the winter time and had to just say no. I'm not even going to attempt it. Snow, ice, steps, no handicap [parking]." –patient C, site 6

The second component was the emphasis on protecting confidential patient information from unintended use. Personnel highlighted the responsibility to protect patient information in accordance to existing legislation on data security.[38] Patients similarly highlighted concerns for identity theft and secure handling of their information.

"Patients feeling like their information is safe and that they feel like their HIPAA [Health Insurance Portability and Accountability Act] is not being violated. I think sometimes the office is a bit like, you're seeing other patients, your information is kind of there…I think that that's an important part of patient safety is making sure their health information is safe." –physician, ID 87, site 10
"In light of everything that's going on in the world today with identity theft, I'm concerned with measures that are taken, that our records will be secure. I'm also concerned that when new applicants come to the clinic to work at the clinic, from doctors all the way down to the person answering the phone…that these people are also reliable and not people that would take our information and somehow use it." –patient B, site 4

Patient Safety as Communicating Attentively. Attentive communication emerged as a theme from the patient focus group data, which was nonnarrated when contrasted with the personnel interview data. Patients felt safe when they perceived that their primary care provider had actively listened and considered the information provided in the course of the clinical encounter. Communication was also integral in the subthemes (3a) coordinating care and (3b) shared decision-making, but we distinguished this theme because of the interpersonal component of active listening and the willingness by personnel to engage in conversations and act on the information being exchanged. Collectively, they underlay a patient-provider relationship that signaled safety to patients:

"We all have different little medical concerns and you can just ask him [the physician] a question and you get an answer so quickly…so I feel safe in the fact that he's actually listening to me and actually hearing everything I have to say…you think you have this and it's like 'no, you don't have that you have this,' and it's so much simpler. You're not so worried because we do go on the Internet and we do read things and you're like oh my God, I have this and I'm going to die. So, I feel safe that he listens to me and that I'm going to get the right results." –patient B, site 5

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