Patient Safety: Blame the Doctor?

20 Aug

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

“Physician, heal thyself” (Luke, 4:23)

Part Two - Blame the system

This is the second of 3 blogs that discusses 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 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 health service staff in patient safety in primary care. ‘Staff’ includes doctors, nurses or other health workers. Two of the studies we included in our review were focused on the role of practice receptionists, who often have a key role in patient safety through communicating with patients and dealing with repeat prescriptions. Administrative staff are also key to patient safety in primary care.

As was noted in Part One of this series of blogs, an important component of “feeling safe” relates to trust in care providers and the quality of inter-personal communication during interactions with health service staff. In the group of 8 studies that were concerned with patients’ perceptions, 2 were concerned principally with the consequences of real harms experienced by study participants. The results highlighted the role of past experiences in health seeking behaviour and showed how apparently trivial insults could spiral into more serious harm within a breakdown in the clinical relationship. These issues could be ameliorated for some people by training (of both staff and patients) concerning effective communication in clinical encounters.

Fourteen of the 48 articles we reviewed were focused on staff perspectives on patient safety. These studies were located in several different countries (USA, UK , Netherlands, Canada, Denmark, Germany  and Australia) and thus the kinds of processes and factors identified can be considered broadly relevant in western medical contexts. For staff, the main issues in patient safety concerned the characteristics or behaviour of staff or patients, doctor-patient communication and professional roles and responsibilities. Again, the main value of the synthesis in this group of papers appeared to be throwing light on those instances where the findings of different studies contradicted each other. For health service staff, these instances related to clinical autonomy, responsibility and emotional engagement with patients. For example, listening to patients was considered important so as not to miss vital information but it might threaten safety if the information given was perceived as irrelevant or distracting from the main issues at hand.

One commonly identified feature of clinical work in primary care was a perceived unwillingness to follow protocols, with GPs preferring to variously follow gut instincts or “do their own thing” (Elder et al., 2006). However, for health service staff the bulk of their concerns related to systems issues and the organisation of care, which is the subject of the concluding blog in this series. For staff, an important aspect related to the need for effective teamwork to promote safety within a context where staff can be held personally responsible for their actions.

One issue put forward by GPs as contributing to safety failures reflected the stressful nature of the job and the kind of work/life balance apparently necessary to operate “safely”. So far as the particularities of clinical and diagnostic work are concerned the dangers of false assumptions and explanations arrived at too hurriedly were both identified as threats to patient safety. The dangers in instantaneous judgements, perhaps based on stereotypes of presenting patients, was also identified as an issue in the ten medication studies. As in the patient studies, effective communication was considered essential, but potentially problematic given competing agendas and pressures on time and resources. There were also problems for GPs in managing rare drugs prescribed by other specialists, perhaps for conditions that were at the limits of their competence to manage (Rahmner et al., 2010).

Taking all of the studies into account, staff had the potential to compromise safety in the following ways:

  • Communication mediated by receptionists
  • Deference on the part of patients can impact effective communication
  • Poorly performing GPs
  • Lack of face-to-face contact between health workers
  • Ad hoc approaches

 Other findings pointed to the ways in which staff can help promote safety:

  • Create a feeling of safety
  • Understand patients’ circumstances, clinical history and needs
  • Training in doctor-patient communication
  • Share knowledge and training with colleagues
  • Teamwork / promote a safety learning culture
  • Open, blame free and effective communication between staff

 On the face of it, the above findings suggest that engendering patient safety in primary care is something that takes time. However, time is often seen to be at a premium in primary care. Further, the relationship between some of the issues we have identified needs further investigation. For example, are some GPs “poorly performing” because of stress or burnout, or due to deficiencies in training or clinical practice? The main point to note is that effective communication between patients and health workers and between different health workers themselves appear as the most important factors. Often, it seems as though the time available for consultations or other communication in health services is challenged by the way that services are set up, organised or run. These considerations form the subject of next week’s blog, which will be the final post in this series.

References

Elder NC, Graham D, Brandt E, Dovey S, Phillips R, et al. (2006) The Testing Process in Family Medicine: Problems, Solutions and Barriers as Seen by Physicians and Their Staff: A study of the American Academy of Family Physicians’ National Research Network. Journal of Patient Safety 2: 25-32.

Rahmner PB, Gustafsson LL, Holmstrom I, Rosenqvist U, Tomson G (2010) Whose job is it anyway? Swedish general practitioners’ perception of their responsibility for the patient’s drug list. Ann Fam Med 8: 40-46.

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