Introduction: A medical home is a patient-centered, multifaceted source of personal primary health care. It is based on a relationship between the patient and physician, formed to improve the patient’s health across a continuum of referrals and services. Primary care organizations, including the American Board of Family Medicine, have promoted the concept as an answer to government agencies seeking political solutions that make quality health care affordable and accessible to all Americans. Methods: Standard literature databases, including PubMed, and Internet sites of numerous professional associations, government agencies, business groups, and private health organizations identified over 200 references, reports, and books evaluating the medical home and patient-centered primary care. Findings: Evaluations of several patient-centered medical home models corroborate earlier findings of improved outcomes and satisfaction. The peer-reviewed literature documents improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home. Patient autonomy and choice also contributes to satisfaction. Although industry has funded case management models demonstrating value superior to traditional fee-for-service reimbursement adoption of the medical home as a basis for medical care in the United States, delivery will require effort on the part of providers and incentives to support activities outside of the traditional face-to-face office visit. Conclusions: Evidence from multiple settings and several countries supports the ability of medical homes to advance societal health. A combination of fee-for-service, case management fees, and quality outcome incentives effectively drive higher standards in patient experience and outcomes. Community/ provider boards may be required to safeguard the public interest. (J Am Board Fam Med 2008;21: 427– 440.)

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The Medical Home: Growing Evidence to Support a New Approach to Primary Care

Importance Improving patient safety is at the forefront of policy and practice. While considerable progress has been made in understanding the frequency, causes and consequences of error in hospitals, less is known about the safety of primary care.

Objective We investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.

Evidence review We searched 18 databases and contacted international experts to identify published and unpublished studies available between 1 January 1980 and 31 July 2014. Patient safety incidents of any type were eligible. Eligible studies were critically appraised using validated instruments and data were descriptively and narratively synthesised.

Findings Nine systematic reviews and 100 primary studies were included. Studies reported between <1 and 24 patient safety incidents per 100 consultations. The median from population-based record review studies was 2–3 incidents for every 100 consultations/records reviewed. It was estimated that around 4% of these incidents may be associated with severe harm, defined as significantly impacting on a patient's well-being, including long-term physical or psychological issues or death (range <1% to 44% of incidents). Incidents relating to diagnosis and prescribing were most likely to result in severe harm.

Conclusions and relevance Millions of people throughout the world use primary care services on any given day. This review suggests that safety incidents are relatively common, but most do not result in serious harm that reaches the patient. Diagnostic and prescribing incidents are the most likely to result in avoidable harm.

Systematic review registration This systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42012002304).

https://qualitysafety.bmj.com/content/qhc/25/7/544.full.pdf

How safe is primary care? A systematic review

Whatever the acronym of the method (e.g., TQM, CQI) or tool used (e.g., FMEA or Six Sigma), the important component of quality improvement is a dynamic process that often employs more than one quality improvement tool. Quality improvement requires five essential elements for success: fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies, and continuous monitoring of performance and reporting of findings to sustain the change.

Tools and Strategies for Quality Improvement and Patient Safety

Background Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. Objective To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. Methods After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. Results Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. Conclusions We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

https://qualitysafety.bmj.com/content/qhc/early/2016/02/22/bmjqs-2015-004456.full.pdf

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

In understanding the safety climate or culture of a workplace, the perceptions and attitudes of the workforce are important factors in assessing safety needs. Safety solutions may fail if they do not take into account these prevailing attitudes and perceptions. Also, changes in attitudes and perceptions about safety are often likely outcomes of safety interventions. The aim of this study was to develop a measure of perception and attitudes about safety as an indicator of safety culture for use with working populations. After reviewing the structure and content of a number of older, related measures of safety attitudes, a 67-item questionnaire was developed. The questionnaire was distributed in a self-administered form to 1560 workers in a wide variety of types of jobs and 660 questionnaires were returned from 7 workplaces with a response rate of 42%. Items were evaluated by Cronbach alpha which showed that the item set shared considerable common variance. Scale development was approached in two ways. First items which were highly skewed were removed, resulting in removal of around half of the items, with very little loss in alpha. The remaining items were then subjected to factor analysis which revealed five factors; personal motivation for safe behaviour, positive safety practice, risk justification, fatalism and optimism. This factor structure showed acceptable psychometric properties. Second, in an effort to produce a unidimensional scale with a small, but representative set of items, additional items were removed which had high correlation with other items. This resulted in loss of around half of the remaining items. The short scale contained 17 items with again overall acceptable psychometric properties. The most striking finding in the development of this questionnaire was that there was little variation between respondents on a very large proportion of the questions originally selected. Clearly there are well-known beliefs about safety in the working community which need to be understood in order to progress the concept of safety culture.

The development of a measure of safety climate: The role of safety perceptions and attitudes

BACKGROUND AND OBJECTIVES: Each primary care practice should be viewed as a complex adaptive micro-system with its own unique characteristics. To improve safety, under constraints of limited resources and numerous competing demands, practices need to identify those vulnerabilities that pose the greatest risks and focus efforts on these. The Objective was to develop and test a novel methodology that forms self-empowered learning teams that can prioritise safety problems based on the combination of error frequency and severity of consequences, and then devise feasible interventions.METHODS: A survey instrument was designed and used to elicit, in qualitative terms, staff perceptions of frequency, p, and severity, s, of various types/causes of primary care errors. The qualitative responses were quantified using an algorithm that allowed for risk aversion. Relative hazard rate, h = pxs, was used as the basis for prioritising safety problems in two primary care test practices.RESULTS: Each site identified its o...

Building Learning Practices with Self-Empowered Teams for Improving Patient Safety:

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Whistlers detected and analyzed by Automatic Whistler Detector (AWD) at low latitude Indian stations

Evidence suggests that the quality of care delivered by the healthcare industry currently falls far short of its capabilities. Whilst most patient safety and quality improvement work to date has focused on inpatient settings, some estimates suggest that outpatient settings are equally important, with up to 200 000 avoidable deaths annually in the United States of America (USA) alone.
There is currently a need for improved error reporting and taxonomy systems that are useful at the point of care. This provides an opportunity to harness the benefits of computer visualisation to help structure and illustrate the 'stories' behind errors.
In this paper we present a concept for a visual taxonomy of errors, based on visual models of the healthcare system at both macrosystem and microsystem levels (previously published in this journal), and describe how this could be used to create a visual database of errors. In an alphatest in a US context, we were able to code a sample of 20 errors from an existing error database using the visual taxonomy.
The approach is designed to capture and disseminate patient safety information in an unambiguous format that is useful to all members of the healthcare team (including the patient) at the point of care as well as at the policy-making level.

https://hijournal.bcs.org/index.php/jhi/article/download/662/674

A concept for a visual computer interface to make error taxonomies useful at the point of primary care

BACKGROUND Lewy body dementia is a common but frequently underdiagnosed cause of dementia often mistaken for the more familiar entity of Alzheimer disease. Clinically the distinction is important, because it can have profound implications for management. METHODS The medical literature was searched using the keywords "Lewy bodies," "Lewy body dementia," "Alzheimer dementia," and "parkinsonian disorders." A case of Lewy body dementia is described. RESULTS An elderly man had long-standing diagnoses of Alzheimer disease and Parkinson disease. After he was evaluated thoroughly, the diagnosis was revised to Lewy body dementia, leading to changes in treatment that were associated with dramatic improvement in the patient9s mental status. Evidence from the literature suggests that Lewy body dementia can be diagnosed in primary care settings based on clinical criteria. The physician should be alert to this diagnosis, and special attention should be paid to dementia patients who exhibit parkinsonism, hallucinations, fluctuating cognition, or prominent visuosperceptual deficits. CONCLUSIONS The diagnosis of Lewy body dementia has important implications. It is associated with a high incidence of neuroleptic sensitivity, necessitating great caution in the use of these common antipsychotic agents. Early studies indicate cholinesterase inhibitors can be beneficial for treating the hallucinations and behavior disturbances that afflict these patients and might also improve cognition.

Lewy body dementia: case report and discussion.

Medical errors are a major cause of harm to patients. The World Health Organization has, therefore, formed an Alliance for Patient Safety. Reports on error are a rich source for understanding of causes, cascades and consequences. Improvements in safety can result through lessons learnt from these. There are loud and clear calls for the development of appropriate error reporting and taxonomy systems, that are useful at the point of care and policy levels. The urgency expressed in these calls presents a challenge and an opportunity to harness the power of computer visualisation that can help structure and illustrate the |story| of an error in a universal language. This can overcome the shortcomings of current reporting methods and help create an unambiguous international error taxonomy. Presented here is a concept for a web-based visual error reporting system. Although the ambulatory care domain is used for illustration, this concept can provide a user-friendly, efficient means of reporting errors in any domain of healthcare. This unambiguous structured visual modelling, aided by touch-screen technology, is useful to all members of healthcare teams, especially policymakers and patients. Patients particularly are a major source of knowledge on the state of safety in all healthcare settings that is waiting to be tapped.

Sonjoy Singh

Papers

Building Learning Practices with Self-Empowered Teams for Improving Patient Safety:

Whistlers detected and analyzed by Automatic Whistler Detector (AWD) at low latitude Indian stations

A concept for a visual computer interface to make error taxonomies useful at the point of primary care

Lewy body dementia: case report and discussion.

Creating a common vision for all stakeholders to make healthcare safer with interactive visual modelling