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.

Results: The 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.

Discussion: The 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.

Figure 1.

Problems throughout the process of care. * Typology codes:

1. Access breakdown, difficulty contacting office, involving telephone system, telephone not answered, and excessive time on hold.

2. Relationship breakdown, intermediary imposed on communication with clinician; and access breakdown, no return of telephone call.

3. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, rude behavior.

4. Inefficiency of care, duplicative registration.

5. Access breakdown, excessive office waiting time.

6. Relationship breakdown, disrespect or insensitivity, evident in patient flow in the office, prioritizing patients based on race.

7. Relationship breakdown, inadequate time with provider.

8. Technical error, deficiency in history, incomplete history of medications.

9. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient advice ignored.

10. Technical error, deficiency in treatment or follow-up, results of investigations not shared with patient.

11. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient preferences not respected.