Patient Safety: Blame the Patient?

12 Aug

by Gavin Daker-White, Research Fellow, NIHR Greater Manchester PSTRC, The University of Manchester

Cause and effect are never divided between two people
(Max Frisch, I’m Not Stiller)

Part One - Blame the patient-

According to the World Health Organisation, “Patient Safety” can be defined as the “reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.” This is the first of 3 blogs that discuss the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 reports of studies grouped into 5 topic areas:

1. Patients’ perspectives around safety (8 articles)
2. Staff perspectives on safety (14 articles)
3. Medication safety (10 articles)
4. Organisational or management issues (7 articles)
5. Care transitions between primary care and hospitals (9 articles)

The findings of the review were seen to boil down to those that blamed patients for safety failures, those that blamed doctors and those which explained safety failures by shortfalls in clinical systems or the organisation of care. This blog looks at the role of patients in their own safety.

From the first of the 8 published studies concerned with patients’ perceptions of patient safety, it was noted how “trivial insults could eventually lead to more serious problems” (Kuzel et al., 2004). Thus, in another study the authors were explicitly concerned with the kinds of actions or processes that could be seen to maximise the impact of harm once an error had occurred (Elder et al. 2005). For example, if a patient became angry following an encounter with a health professional who refused to refer them on to a specialist, that might affect trust in doctors or future use of services.

Technology is increasingly a feature of health care. A study concerned with patient preferences regarding the notification of test results found that “privacy” and “assured confidentiality” were important concerns which could lead to suspicions around the use of new technologies (Baldwin et al., 2005). Similarly, another study showed how a kind of blind faith in Electronic Health Records (EHRs) could represent a safety risk given the awareness that “patient information in the EHR was scattered, incomplete, or inaccurate” (Baran et al., 2011).

One message that derived from this group of studies was that when patients had more experience of health services they were better equipped to identify potential risks and take steps to avoid or reduce harm. In this context, patient safety appeared as a ‘feeling’ engendered through successful relationships and encounters with health professionals.

In the 14 studies concerned with the perspectives of health service staff, the characteristics or behaviour of patients appeared as important factors seen to impact on safety. These factors also appeared important in the 10 studies focused on medication errors. Both groups of findings pointed to the difficulties encountered in consultations with patients with multiple health conditions (so-called ‘multimorbidity’) or problems related to hearing, comprehension and memory. So far as medications were concerned, some patient’s characteristics were seen to limit the likelihood of adherence to drug regimens and also created challenges for receptionists in understanding older patients’ prescription requests (Hesselgreaves et al., 2009).

In sum, the findings suggested that the following characteristics or behaviours of patients appear as threats to patient safety in primary care:

• Disadvantages (physical, educational, level of comprehension and understanding)
• Complex symptoms
• Problematic presentation
• Lack of health literacy and self-management skills
• Social circumstances (e.g. living alone)

By extension, individual patients could promote their own safety by becoming more actively involved in their own care, by taking more responsibility for their own care, by becoming better informed about their health conditions and skilled in the self-management of their symptoms. This was especially evident in research that had looked at safety around hospital discharge. However, the findings around becoming more active in health care encounters in other groups of studies (e.g. medications) were sometimes contradictory which suggests the need for further research about what works in this context. It was also clear that patients can help minimize the risks in health care by being adaptable in response to system requirements.

There is a tension evident in the findings concerning the safety ‘risks’ associated with patients, however. For example, somebody who faces disadvantages, complex symptoms or lacks social support might find it harder to manage their conditions or become more actively involved in their own care. These are issues we are exploring in ongoing research within the Multimorbidity research theme of the NIHR Greater Manchester PSTRC. In one study we are following people over time to learn about threats to safety and what patients might be able to do about them (“MAXIMUM”). In a video study for the website healthtalk.org we will explore the health care dilemmas faced by people with multiple health conditions and how they cope with health conditions in different ways.

The findings of our review can be used to inform patients more generally about how to enhance their safety in healthcare. Of course some patient characteristics that can be seen to affect safety (e.g. being cognitively impaired or living in particular social or economic circumstances) are less easy for people to do anything about themselves. However, this points to situations or circumstances in which it could be beneficial to make use of advocates or carers for maintaining safety vigilance. Alternatively, instances where staff or services need to monitor cases or processes with extra detail or care are highlighted.

The influences of health care staff on patient safety will form the next blog in this 3-part series.

References

Baldwin D, Quintela J, Duclos C, Staton E, Pace W (2005) Patient preferences for notification of normal laboratory test results: A report from the ASIPS Collaborative. BMC Family Practice 6: 1-7.

Baran SD, Lapin JA, Beasley JW, Smith PD, Karsh B-T (2011) Identifying Hazards in Primary Care: The Elderly Patient’s Perspective. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 55: 1130-1134.

Elder NC, Jacobson CJ, Zink T, Hasse L (2005) How experiencing preventable medical problems changed patients’ interactions with primary health care. Ann Fam Med 3: 537-544.

Hesselgreaves H, Lough M, Power A (2009) The perceptions of reception staff in general practice about the factors influencing specific medication errors. Educ Prim Care 20: 21-27.

Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, et al. (2004) Patient reports of preventable problems and harms in primary health care. Ann Fam Med 2: 333-340.

Tsang C, Majeed A, Aylin P (2012) Consultations with general practitioners on patient safety measures based on routinely collected data in primary care. JRSM Short Rep 3: 5.

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