Perspectives on Safety

Patient Safety in Primary Care

Introduction

A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare for all Americans.[1] Primary care services have been linked to increased life expectancy and decreased mortality from conditions such as cardiovascular disease, cancer, and respiratory disease.[2] Important services delivered by primary care clinicians include health promotion and disease prevention, care for acute conditions, diagnosis and management of chronic conditions, follow-up care after hospital discharge, and care coordination.[3] However, numerous challenges affect the safety of care received by patients in the primary care setting. Articles AHRQ PSNet published on this topic in 2019 highlighted the scope of potential patient safety challenges, including the types of error and the wide variety of patient populations that may be affected. The examples highlighted in 2019 and in this essay include:

  • Inappropriate and overprescribing
  • Poor communication and care coordination
  • Diagnostic errors and delays

Articles also highlighted a variety of solutions to these challenges that could be applicable and actionable for primary care practices of different sizes, organizational structures and provider types.  

Inappropriate and Overprescribing

Inappropriate and overprescribing in primary care can occur in all patient populations and may lead to negative health outcomes, particularly in older persons. Beyond acute patient safety events, some inappropriate prescribing can have broader public health safety concerns. These predominantly relate to inconsistent practices driving the prescribing of opioids and antibiotics that have contributed to the opioid epidemic and the rise of antibiotic resistant infections.[4],[5]

Potential strategies

Several strategies may alleviate the risk of inappropriate prescribing. These include surveillance approaches, such as automated phone calls, that target patients prescribed specific medication classes. These can help to detect and prevent potential adverse events. One study found that automated phone calls with the option of transfer to a live pharmacist were effective at detecting potential adverse events in primary care patients prescribed medications for hypertension, diabetes, depression, and insomnia. Another example is increasing the use of shared decision-making and increased patient engagement with clinicians prior to prescribing decisions. Increased shared decision-making can ensure that treatment options align with patient preferences and ensure that medication risks are adequately discussed. Shared decision-making has been demonstrated to support appropriate medication prescribing in patients receiving polypharmacy.[6] Additionally, implementation of interventions like shared decision-making tools help to standardize treatment decisions and give clinicians a consistent framework that may minimize external factors influencing prescribing.

Poor Communication and Care Coordination

There are significant challenges and weaknesses in communication between primary and specialty care providers and amongst primary care providers. This can jeopardize or delay the development of an accurate diagnosis and treatment plan. Additionally, ineffective coordination following hospital discharge can decrease likelihood of timely primary care follow-up visits, increase the risk of adverse events or complications, and increase the risk of hospital readmissions. 

Potential strategies

As identified in a 2019 AHRQ report, there are numerous interventions that primary care practices can apply to enhance communication and care coordination to improve patient safety. Examples include, but are not limited to:

  • Automated alerts when patients are hospitalized to ensure primary care clinicians are able to communicate with hospital teams as necessary.
  • Post-discharge phone calls to facilitate early identification of complications.
  • Bundled care coordination approaches that incorporate multiple interventions that more accurately align with the complexity of patients treated in primary care practices.
  • Comprehensive care transformation efforts, such as patient-centered medical homes, that include care coordination embedded within their framework and may even include financial incentives.
  • Explicit agreements on the roles and responsibilities surrounding patient care between the primary care practice and other institutions within the community, such as hospitals and nursing homes, to reduce disconnects in follow-up care and increase communication accountability between providers.

Diagnostic Errors and Delays

Diagnostics errors, particularly missed or delayed diagnoses, are a common source of error in the primary care setting for both pediatric and adult populations.[7]  Missed cancer diagnosis is a leading type of diagnostic error and studies indicate that provider communication approaches and system factors, such as difficulty scheduling follow-up appointments, are contributing factors. While these articles discuss these factors specifically in the context of missed cancer diagnosis, they have also been shown to contribute to diagnostic error for other health conditions.[8]

Potential strategies

One approach is to implement improvement initiatives that target specific diagnostic errors. For example, one AHRQ toolkit is designed specifically to standardize primary care laboratory testing processes. A 2019 study evaluating toolkit implementation found that the toolkit was easy to use and that practice staff found guidance for engaging patients regarding test results particularly beneficial. Other initiatives practices may consider include interactive educational webinars, provider coaching, use of root cause analysis tools, and regular data collection. 

In 2019, a multidisciplinary panel consisting of clinicians, educators, and health policy communication experts convened to establish a set of ten diagnostic principles for more conservative, “care-full” diagnosis. These principles emphasize the need for continuity between clinicians and patients to build trust and foster timely diagnosis.  Stronger relationships between patients and clinicians can reduce over diagnosis and overtreatment and may also support reducing missed diagnosis.

Finally, collective intelligence platforms have the potential to facilitate providers connecting and collaborating with one another as they approach diagnosis challenges. As this study found, these types of IT platforms are most useful to providers when they are simple to use and developed from trusted sources.

Areas for Future Research

Many of the safety concerns described in this essay share similar underlying etiologies. Additional research into solutions for cross-cutting contributing challenges could enhance the overall safety of primary care. 

A key cross-cutting challenge is determining how to improve reliability without placing additional burden on primary care clinicians. For example, careful manual clinician follow-up and monitoring of specialist referrals to ensure they are carried out in a timely way will likely minimize the number of patients who “fall through the cracks,” but it is labor intensive and not very efficient. Yet simply placing a referral order with no follow-up may be efficient but is not very reliable in ensuring the patient receives the specialist care they require. Finding ways to more effectively use teamwork to reduce perceived provider burden and burnout, while at the same time ensuring significantly and consistently higher levels of care process reliability, could be a critical next step to improving the safety of patient care across all of the challenges discussed. Systems engineering approaches and redesign of burdensome and problematic electronic medical records will be required.   

A second challenge is countering the continued pervasiveness of fragmented and siloed delivery systems. This greatly hinders the ability for cohesive teamwork, communication, and coordination across settings and limits the efficiency of providing safe care. Technology developments related to information interoperability may be able to alleviate some of these challenges by increasing provider access to patient information. However, improvements in interoperability and increased sophistication of data collection bring an additional cross-cutting challenge: the burden of too much information. Absent of more thoughtful design, the exponential growth in the amount of information and data providers have access to may actually make matters worse, as clinicians struggle to a) maintain awareness and access the totality of information that is available and b) efficiently, and appropriately apply this disparate clinical information for the patient in real time during primary care encounters.

A final cross-cutting challenge concerns the quality of relationship between the primary care provider and the patient. Patients report feeling dissatisfied that they are not being heard, with the feeling that the electronic health records has directed provider attention away from personal interactions with the patient.[9] A recent review of best practices to promote clinician presence, points to simple ways clinicians could more meaningfully enhance connections with patients[10] with the possibility of positively impacting numerous safety targets, such as accuracy of diagnosis and medication adherence.9   

Identifying innovative solutions to these challenges may not only alleviate the safety concerns previously described, but also improve the overarching safety of primary care.  

 

Contributing authors have nothing to disclose.

Gordon Schiff, MD
Associate Director, Center for Patient Safety Research and Practice

Division of General Internal Medicine, Brigham and Women's Hospital

Associate Professor of Medicine, Harvard Medical School

Quality and Safety Director, Harvard Medical School Center for Primary Care

Boston, MA

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health

IMPAQ International

Columbia, MD

Eleanor Fitall, MPH
Research Associate, IMPAQ Health

IMPAQ International

Washington, DC

References


[1] Transforming the organization and delivery of primary care. Agency for Healthcare Research and Quality website. https://pcmh.ahrq.gov/. Accessed February 18, 2020.

[2] Levine DM, Linder JA, Landon BE. Characteristics of Americans with primary care and changes over time, 2002-2015. JAMA Intern Med. 2019. [Epub ahead of print]. doi: 0.1001/jamainternmed.2019.6282. [PudMed]

[3] Primary Care. American Academy of Family Physicians website. https://www.aafp.org/about/policies/all/primary-care.html. Accessed January 27, 2020.

[4] McDonagh MS, Peterson K, Winthrop K, Cantor A, Lazur BH, Buckley DI. Interventions to reduce inappropriate prescribing of antibiotics for acute respiratory tract infections: summary and update of a systematic review. J Int Med Res. 2018;46(8):3337-3357. doi: 10.1177/0300060518782519. [PubMed]

[5] Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf. 2014;5(6):229-41. doi: 10.1177/2042098614554919. [PubMed]   

[6] Coronado-Vazquez V, Gomez-Salgado J, Cerezo-Espinosa de Los Monteros J, Ayuso-Murillo D, Ruiz-Frutos C. Shared decision-making in chronic patients with polypharmacy: An interventional study for assessing medication appropriateness. J Clin Med. 2019;8(6). doi: 10.3390/jcm8060904. [PubMed]  

[7] Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi: 10.1136/bmjqs-2016-005401. [PSNet]    

[8] Lee CS, Nagy PG, Waver SJ, Newman-Toker DE. Cognitive and system factors contributing to diagnostic errors in radiology. Am J Roentgenol. 2013;201(3):611-7. doi: 10.2214/AJR.12.10375. [PSNet]   

[9] Sanders L, Fortin AH, Schiff GD. Connecting with patients – The missing links. JAMA. 2020;323(1):33-34. doi: 10.1001/jama.2019.20153. [PubMed]     

[10] Zulman DM, Haverfield MC, Shaw JG, et al. Practices to foster physician presence and connection with patients in the clinical encounter. JAMA. 2020;323(1):70-81. doi: 10.1001/jama.2019.19003. [PubMed]