Abstract
ObjectiveStudies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.MethodMeta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.ResultsForty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients’ perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from ‘grand’ systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.ConclusionOverall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.
Highlights
There is a long standing literature on the “iatrogenic” harms that can arise from medicine or health systems
The study described in this article used meta-ethnography as a means of synthesizing the findings of studies as originally designed for use in Education research [22] and later developed for use in health services research [25]
The findings were organised around errors related to access, communication, relationship breakdowns, technical errors and “inefficiency.” This key article for the synthesis was most useful for demonstrating how “trivial insults could eventually lead to more serious problems” [35]
Summary
There is a long standing literature on the “iatrogenic” harms that can arise from medicine or health systems. Since increasing research has concerned patient safety from a variety of theoretical perspectives, these have tended to focus on hospital medicine [2,3,4]. Treatment and care is usually administered directly by health care workers. In ambulatory settings, including primary care, treatments such as prescribed medications are usually administered by patients’ themselves. For this and other reasons, patient safety has particular features in primary care including diagnostic uncertainty, the management of polypharmacy, a culture of continual organisational change and the potential for “information overload” [5]
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