Why It Matters
While patient safety risks in the hospital setting are well known, it can be easy to overlook the risks of harm in primary care.
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6 Ways to Make Primary Care Safer

By Jennifer Lenoci-Edwards | Friday, September 11, 2015

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:

        • Can sick patients in your practice see their primary care provider in a timely fashion?
          Are you providing care that prevents avoidable hospital admissions or readmissions?

2. Close the loop on test results:

        • Does your practice know if all patients referred for urgent testing have completed that testing?
        • Do you review urgent test results in a timely manner?
        • Do you clearly convey test results and what they mean to your patients?
        • Do you use evidence-based medicine to decide whether or not to do further testing?

3. Follow through on important referrals:

        • Do your patients follow through when you make an urgent referral?
        • Do you get information on your patients from the specialists to whom you make referrals and then review it?
        • Do you communicate with your patients about specialist assessments and recommendations?

4. Build back-up systems:

        • Do you have a good system in place to follow up on tests and referrals when a clinician is on vacation or unexpected leave?

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. 

        • Do your care team members feel respected?
        • Does your team feel appreciated and acknowledged for their hard work?
        • If there is a near miss or a safety event, does your practice provide a safe environment that encourages team members to report such issues to management?
        • Do you have a Just Culture focused on system improvement versus individual blame?

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.


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