Patient safety initiatives turn focus toward primary care

For the first time, a patient safety conference looks at the office setting.

By Andis Robeznieks, amednews staff. Oct. 6, 2003.

Most attention from the patient safety movement has been on hospital-based settings. Now some researchers believe it's time to take a giant step forward and investigate interventions that would improve safety in the primary care physician's office.

"I think the next step is all of us moving into the next level of research: interventions," said Nancy C. Elder, MD, an assistant professor with the University of Cincinnati Dept. of Family Medicine. "That's where we need to go. I was recently asked to give a talk on evidenced-based interventions, but I couldn't do it because there isn't enough evidence."

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Dr. Elder and about 100 other physicians, pharmacists, administrators and engineers were in Chicago recently for a conference focusing on patient safety in the primary care setting. The conference was reportedly the first of its kind and was sponsored by the Primary Care Organizations Consortium, the American Academy of Family Physicians and the Dept. of Family Medicine at the University of Chicago's Pritzker School of Medicine. It was funded by a $50,000 grant from the U.S. Agency for Healthcare Research and Quality.

Common errors that were discussed included mixing test results of patients with the same name, diagnostic errors, laboratory test and x-ray foul-ups (one presenter told of a courier putting a pile of x-rays on top of his car and then driving off), administrative errors, knowledge and skill errors, and the different definitions of patient harm.

Dr. Elder said the type of research discussed at the forum was so new, very little has been published, and that made a conference of this type all the more necessary.

"Since nothing's really been published yet, this is the only way we can see what our colleagues are doing," she said. "I didn't realize that there were so many people in so many locations doing this type of work."

Anton Kuzel, MD, vice chair of the Family Practice Dept. at Virginia Commonwealth University, Richmond, agreed. "I'm really happy that this happened, and it's clear that we really needed to bring this group together," said Dr. Kuzel, who called patient safety "the elephant in the room" that nobody talks about in ambulatory health care.

John Hickner, MD, professor of family practice and associate chair for research at Michigan State University College of Human Medicine, East Lansing, served as principal investigator for the conference, and he reported on a pilot study that highlighted the problems with many error-reporting systems. In particular, Dr. Hickner noted how few knowledge and skill errors were reported -- but that was understandable.

"We can't report what we don't know," he said.

Donna Woods, PhD, a fellow at the Institute for Health Services Research and Policy Studies at Northwestern University, Evanston, Ill., and Gerald Hickson, MD, associate dean for clinical affairs at Vanderbilt University Medical Center in Nashville, Tenn., noted how this highlighted the need for more feedback between doctors. Dr. Woods also said that physicians who spot an incorrect diagnosis should find out how the misdiagnosis was made.

Dr. Hickner later noted that physicians are trained to be "the Lone Stranger" when they really need to be trained in systems and teamwork. "Our next step is to take [patient safety] from reporting to doing something about it."

Dr. Kuzel said reporting patient harm is difficult because there seems to be no standard definition. He presented results of a study indicating that 70% of incidents reported by patients referred to "psychological harm," which included feelings of anger, frustration, loss of trust and perceived racism.

Reflecting on how the conference went, Dr. Kuzel later said "medical error" describes a broad spectrum of issues. "Many people have the feeling of not being listened to or cared for. I see that as an error," he said. "They need to walk away thinking that both these needs were met."

In addition to system errors that lead to patients not being able to get an appointment or a question answered, he said there are other big-picture problems that need to be fixed.

"Forty-two million Americans are without health insurance. To me that's a system design flaw, and that represents a huge error in our health care system."