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


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

In This Article


We identified 5 work functions on how frontline clinicians, administrators, staff, and patients conceptualize the meaning of patient safety in primary care. The conceptual meanings of patient safety to personnel working in primary care are largely consistent with those of patients with some divergence: coordinating care, where personnel were focused on the tasks involved, but patients were focused on the relationships instead; considering social determinants of health, which was nonnarrated in patients' conceptualization of safety; and communicating attentively, which was nonnarrated in personnel's conceptualization of safety. By systematically investigating how frontline clinicians, administrators, staff, and patients conceptualize patient safety in primary care, this study responds to calls to include the patient perspective in patient safety research[39] and seeks to provide some foundational context that may help advance future patient safety efforts in primary care.[40]

Experts have highlighted the importance of 5 safety domains in primary care: medications, diagnosis, care transitions, referrals, and testing.[4,7] However, our findings indicate that (1) function-based conceptualizations of patient safety better reflect the experiences of personnel than domain-based conceptualizations; (2) informational security, which is not highlighted in the expert view, is also perceived as an element of patient safety in primary care; and (3) conceptualizations of patient safety in primary care have a large overlap with those in quality of care.[41] Of note, the considerations in both the function-based or domain-based conceptualization are largely consistent. The theme Not Causing Harm had a particular emphasis on medication safety. The theme Providing Appropriate and Timely Care emerged from participants' descriptions around diagnoses, care transitions, referrals, and testing. This study instead demonstrates that personnel conceptualize patient safety more in terms of work functions that traverse these domains. Second, there may be a need to extend the existing foci in primary care safety beyond the clinical domains to include issues related to informational security and confidentiality.[25] Collectively, these findings can inform how and what to start measuring patient safety performance in primary care, especially when the number of safety indicators specific to primary care remains limited compared with the inpatient measures.[42,43]

The analytic classification of a personnel or patient perspective as nonnarrated does not sufficiently indicate that it is not considered important and/or an element of patient safety to them. This study sought to capture the meanings of patient safety that were most salient to the participants. A lack of narration may therefore be resultant of what participants considered to be associated with patient safety or not, instead of a complete absence of conceptualization. The subtheme considering social determinants of health was classified as nonnarrated in patients' conceptual meaning of patient safety in primary care when juxtaposed with that of personnel. As a concept, SDOH is challenging to understand generally,[44] which may explain why patients did not articulate particular social factors and their influence on health as a part of patient safety in primary care as much as personnel. An alternative explanation is that patients may not consider SDOH as a domain of responsibility under their primary care provider. Future research should address how SDOH and patient safety are being considered in the delivery of primary care to gain clarity on this aspect of safety.

As personnel in PCMHs conceptualized care coordination as a part of the meaning behind patient safety in primary care, they adopted a task orientation, in which the focus was to conscientiously complete tasks to ensure that patients' care coordination needs were being met. In comparison, patients adopted a relationship orientation to care coordination. Patients placed more weight on the trust in their primary care provider to refer them to other health care professionals that were able to meet their health care needs. From the patient perspective, care coordination activities in the context of patient safety are therefore not limited to their primary care provider(s) but also extend to the external professionals whom they are being referred to. To enhance patients' perceptions of safety, primary care practices can consider emphasizing relevant information (eg, history of referring patients to this particular specialist and feedback from other patients) to foster the trust that underlies patients' construal of safety.

Last, patients conceptualized attentive communication as part of patient safety in primary care. They perceived care as safe when their primary care provider actively listened and considered the information they provided as diagnostic and treatment-related decisions were being made. This is also compatible with a function-based conceptualization of patient safety. In particular, patients perceive care delivery to be safer when their primary care providers can demonstrate that they are paying attention to the information being shared by the patient during the clinical visit. Previous research has highlighted the importance of "patient-centered communication" when delivering care, which also increases patient satisfaction.[45–47] Specifically, researchers have defined listening both as a pragmatic strategy to reduce medical errors, and a social strategy to foster interpersonal connections.[46] The pragmatic as well as social dimensions during clinical encounters should therefore be considered in efforts to better align with this conceptual meaning of patient safety.

Study Limitations

Most patients in the focus groups identified as white; thus, our findings may not be fully indicative of the perspectives among the primary care patient population. In addition, we conducted this study in the context of level 3 PCMHs, which was the highest level of recognition in the NCQA's PCMH model during the study period. The transferability of the findings to other primary care practices that are not level 3 PCMHs, or non-PCMHs, may therefore be limited. However, by targeting high-performance primary care practices like level 3 PCMHs, this study sought to examine a more comprehensive range of conceptual meanings of patient safety in primary care that may not have been fully considered in other primary care practices.