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Patient Safety/Quality

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Many primary care errors stem from problems with access to clinicians and doctor/patient interaction

The current focus of the patient safety movement on drug errors and surgical mishaps may overlook other patient priorities, according to a recent study. The researchers found, for example, that many errors reported by primary care patients involve breakdowns in access to and relationships with clinicians and do not involve technical errors in diagnosis and treatment. These breakdowns led to anger and frustration and, in some case, to worsened or untreated medical conditions and adverse drug reactions.

For the study, which was supported by the Agency for Healthcare Research and Quality (HS11117), Steven H. Woolf, M.D., M.P.H., of Virginia Commonwealth University, and his colleagues conducted in-depth interviews with 38 adults from rural, suburban, and urban locales in Virginia and Ohio. Their goal was to solicit stories of preventable problems with primary health care that led to physical or psychological harm.

Rushed, dehumanized health care experiences pervaded the narratives. Analysis of the interview transcripts revealed 221 problematic incidents, 37 percent of which involved breakdowns in the clinician-patient relationship. For instance, the clinician did not spend adequate time with the patient or ignored the patient's comments or preferences. Communication breakdowns also occurred during the visits. For example, the wrong chart was used for a patient, a referral was not done, or a medication refill was not called to the pharmacy.

Twenty-nine percent of problematic incidents involved difficulty gaining access to clinicians. For example, the office telephone often went unanswered (or patients were left holding for long periods of time), office waiting time was excessive, and referrals to a specialist were delayed. These incidents were linked to 170 reported harms, 70 percent of which were psychological, including anger, frustration, belittlement, and loss of relationship and trust in the clinician. Physical harms accounted for 23 percent of the total and included pain, bruising, worsening medical condition, undertreated and untreated conditions, and adverse drug reactions.

Details are in "Patient reports of preventable problems and harms in primary health care," by Anton J. Kuzel, M.D., M.P.H., Dr. Woolf, Valerie J. Gilchrist, M.D., and others, in the July 2004 Annals of Family Medicine 2(4), pp. 333-340.

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