Daker-White Gavin, Hays Rebecca, Blakeman Thomas, Croke Sarah, Brown Benjamin, Esmail Aneez, Bower Peter
NIHR Greater Manchester Patient Safety Translational Research Centre (Greater Manchester PSTRC), Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
NIHR School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
BMC Fam Pract. 2018 Sep 8;19(1):155. doi: 10.1186/s12875-018-0844-0.
In primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care.
Data were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs.
Twenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. "Under" and "over" consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment.
Patient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with 'under' or 'over' consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.
在初级卫生保健中，患者安全失误可能出现在服务获取、医患关系、医护人员之间的沟通、关系及管理的连续性或技术操作等方面。本研究通过多重疾病的视角，并运用定性人种学方法，旨在阐明初级保健中的安全问题。
数据来源于电子健康记录（EHRs）、初级保健会诊观察、对患者、（非正式）医护人员及全科医生的年度访谈，并进行三角互证。对观察、访谈及实地记录材料进行主题分析，以描述所遇到的患者安全问题及任何相关因素或过程。对6个案例进行更详细的纵向描述，以便将观察、访谈及EHRs中确定的安全问题置于具体情境中。
招募了26名患者。在基于已发表文献的框架的所有领域中均发现了可能导致伤害的事件。通过对观察和访谈材料的主题分析，“咨询不足”和“咨询过度”作为安全失误的先兆出现。其他发现涉及工作量（医生和患者的）以及短咨询时间的局限性。直接从患者处收集的健康数据与EHRs中的数据存在差异。例如提及中风病史以及慢性肾脏病和高血压的诊断。案例研究分析揭示了与安全问题相关的特定问题，主要围绕多药治疗的管理和患者用药依从性。临床要务似乎围绕风险管理，但研究结果表明与患者在检查、诊断和治疗方面的期望存在潜在冲突。
患者安全工作给临床医生和患者的现有工作量带来了额外负担。在这种概念中，安全工作似乎构成了与患者安全本身的负反馈循环的一部分。从不同来源的研究结果三角互证得出的一系列观点表明，在尽量减少干扰性医疗的可取性与可能与“咨询不足”或“咨询过度”相关的安全风险之间存在紧张关系。多重疾病是全科医疗中卫生服务提供和优质护理方面紧张关系的放大器。应更多关注系统设计而非患者或专业人员的行为。
