IHI Patient Safety Director Jennifer Lenoci-Edwards describes the moment she realized that safety means different things in different settings. She also outlines recommendations for improving primary care patient safety. Lenoci-Edwards is faculty for IHI’s upcoming program, Building Reliable Systems to Reduce Delays in Diagnosis.
Before starting my role as director in IHI’s patient safety focus area
, I spent a year helping primary care teams work toward their Patient-Centered Medical Home certification. I taught them the basics of quality improvement, teamwork, and the importance of culture.
Equipped with my knowledge of what safety means in the inpatient setting, I was determined to incorporate harm prevention into all of our work. In the early months in my role I always asked each primary care team, “What types of safety events or harms have occurred at your practice?” The response was always the same: “We have not had a safety event in months. No one has fallen and we have not administered the wrong medication. We are a very safe practice.” After six months on the job, I realized something important: safety doesn’t mean the same thing in primary care as it does in hospitals.
For example, one day, I entered an office practice with the intention of helping them improve their system for referral management:
Me: Do you have a reliable system for referral management?
Office Manager: Yes, we do. We have a dedicated referral manager who inputs all referrals into an electronic spreadsheet. Physicians complete a standard template in our EMR noting the reason for referral, referring MD, notes, and level of urgency.
Me: Wow, this is amazing. [I meant it; not many sites were this advanced in tracking their referrals.]
I then sat down with the referral manager to learn more:
Me: Your referral system sounds great. I am very impressed. Tell me about your process. Do you close the loop on all these referrals at the practice?
Referral Manager: No, there are too many to count. I do as many as I can.
Me: Okay, that’s fair. Does your process ensure you are closing the loop on the most serious referrals, like the patients referred for diabetes, cancer, or other worrisome conditions? Can you tell the difference between a referral for acne or diabetes in your system?
Referral Manager: No, we don’t, and no, we can’t.
Most health care professionals could easily provide examples of harm events in hospitals, including wrong-side surgeries, medication errors, falls, and pressure ulcers. Listing the types of harms that happen in primary care offices, on the other hand, may prove more challenging because they are more subtle and camouflaged in daily routines. Examples include delayed diagnosis because of poor test or referral management, treatment or diagnostics that don’t follow evidence-based protocols, and omitted or inadequate medication reconciliation. Not fully understanding a patient’s needs and the barriers to their best health can also harm patients. Sometimes the results of unintended harm to patients in primary care don’t appear for years, but that doesn’t make this issue any less urgent.
Here are six recommended ways to make primary care safer:
1. Improve access:
2. Close the loop on test results:
3. Follow through on important referrals:
4. Build back-up systems:
5. Address social barriers to safety:
Do you assess the social factors that could lead to patient safety events? For example, do you explain patients’ conditions and medications in language that is easy for them to understand?
Do you offer appropriate and competent support for patients with limited English proficiency?
- Do you know whether your patients can afford the medications you prescribe?
6. Improve workplace culture: A poor workplace culture may not seem like a contributor to patient harm, but workplace satisfaction is key to engaging care teams in doing their best for patients.
Safety is about preventing patient harm. As people trusted to ensure patients’ best health, health care providers need to make sure patients are safe, especially in the clinical setting where the vast majority of patients receive their health care.
What do you think patient safety means in the primary care setting? What practices have you implemented to ensure primary care safety?
Learn more about resources for developing reliable systems and processes.