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.

Abstract and Introduction

Abstract

Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective.

Methods: We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes. We used thematic analysis to approach coding.

Results: Findings indicate that frontline personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Frontline personnel and patients conceptualized patient safety in largely consistent ways.

Discussion: Function-based conceptualizations of patient safety in primary care may better reflect frontline personnel and patients' experiences than domain-based conceptualizations, which are favored by experts.

Introduction

Improving patient safety can not only avert preventable deaths but also reduce morbidity, costs, and distress for patients as well as health care professionals.^[1,2] Since the Institute of Medicine published "To Err is Human",^[3] patient safety efforts have proliferated; although, they have focused more on the inpatient setting than its ambulatory counterpart.^[4] Yet, 23 times more people receive services in primary care than in hospitals in the United States yearly.^[5,6] Expert consensus highlights medications, diagnosis, transitions, referrals, and testing as key domains in primary care.^[4,7,8] Although some of these domains overlap with the inpatient setting, primary care faces additional challenges that may create safety concerns: (1) there is a heavier reliance on patients for disease management; (2) clinical encounters are typically short and episodic; (3) fragmentation exists among electronic health record systems; and (4) practices are more sensitive to changes in size, financing, leadership, and culture.^[4] These characteristics warrant the need to explore patient safety in primary care, especially given our increasing need for health services and limited knowledge of safety issues in this setting.^[9–11]

Previous research on safety in primary care has examined the epidemiology of medication errors,^[12,13] error reporting tools,^[14] and perceptions of safety culture.^[15,16] A distinct way of contributing to this increasingly important area is to investigate what patient safety in primary care means to those on the frontlines delivering care as well as the patients receiving it. This investigation is useful because, first, clarifying conceptual meanings is often a foundational step for addressing burgeoning topics in the health sciences.^[17–19] Second, identifying the meanings generated can help us understand, predict, and improve the actions taken by frontline personnel and patients.^[20–22] Third, patient safety research in primary care has tended to focus on the perspectives of either professionals or patients, without efforts to examine them simultaneously.^[23–25] By systematically eliciting the meanings from a representation of not only professionals but also administrators, staff, and patients, we can include a wider range of conceptualizations and identify elements that are important to, and how they are different across, stakeholder groups. Such findings can generate potential research directions for scholars as well as preliminary ways for managers to think about the design, implementation, and evaluation of patient safety interventions in primary care.

Our primary research aim was to elucidate the conceptual meanings of patient safety among frontline clinicians, administrators, staff, and patients in the primary care setting. Second, we compared and contrasted the meanings to clinicians, administrators, and staff with those to patients to ascertain the degree of alignment.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References
Appendix

Table 1. Demographic Information of 101 Frontline Clinicians, Administrators, and Staff*
Characteristic	Values
Profession^†, n (% of sample)
Administration or management	37 (36.6)
Care coordinator/navigator	9 (8.9)
Medical assistant	11 (10.9)
Nurse	8 (7.9)
Physician	25 (24.8)
Other (dental staff, pharmacist, physician assistant, and social worker)	11 (10.9)
Sex, n (% of sample)
Female	78 (77)
Male	23 (23)
Median number of years working at practice (range)	4 years (1 month – 29 years)

*Participants were from 10 patient-centered medical homes who took part in individual interviews conducted between May 2017 and May 2018 on patient safety in primary care.
^†Respondents who held more than one role (ie, administration and clinical) were classified by their clinical profession in this table.

Table 2. Demographic Information of 65 Patients*
Variable	n (% of sample)
Age range
18–45	10 (15.4)
46–65	22 (33.8)
66–75	20 (30.8)
>75	12 (18.5)
Did not wish to answer	1 (1.5)
Sex
Female	35 (53.8)
Male	26 (40)
Did not wish to answer	4 (6.2)
Race
Asian	1 (1.5)
Black/African American	3 (4.6)
Native American	1 (1.5)
White	55 (84.6)
Did not wish to answer	5 (7.7)
Education
College degree/some college	31 (47.7)
Degree after college	8 (12.3)
High school graduate/some high school	25 (38.5)
Did not wish to answer	1 (1.5)

*From 10 patient-centered medical homes who participated in focus groups conducted between May 2017 and May 2018 on patient safety in primary care.

Appendix. Themes and Illustrative Quotes From Clinicians, Administrators, Staff, and Patients on Conceptual Meanings of Patient Safety in Primary Care

Main Theme (Level of Agreement between Personnel and Patients)	Subtheme (Level of Agreement between Personnel and Patients)	Illustrative Quotes
Not causing harm (agreement)		"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, ID 55, site 6 "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
Viewing the patient as a whole (agreement)		"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 "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…looking at all of me and I like that. I like that feeling." –patient A, site 1
	Social determinants of health (nonnarrated by patients)	"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
Providing appropriate and timely care (agreement)		"First, do no harm. But, in a broader sense, it is the right care for the right patient at the right time. So, expounding on that, it means understanding the patient, their situation, in a timely way, you know, which would involve recognition of issues in a timely way, and then direction into the right treatment pathways." –physician, ID 65, site 7 "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
	Care coordination (partial agreement)	"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 "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 (agreement)	"[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 "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
Ensuring physical safety and informational security of the practice environment (agreement)		"So safe medical care means to me that…when the patient comes in, they can safely get to the chair, they can safely room, you know, 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 "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 "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 secure background checks are made, that these people are also reliable and not people that would take our information and somehow use it." –patient B, site 4
Communicating attentively (nonnarrated by personnel)		"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