Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families

Safety Issues

1. Fragmentation of the care systems and transitions between providers
   Definition: The transition of patients between providers is fragmented, at times resulting in the loss of critical information and valuable time on behalf of the provider and the patient.
2. Communication between patients and providers, health literacy
   Definition: Communication of necessary health information (diagnostic, treatment, prevention, etc.) between patients and providers can be fragmented, infrequent, or nonexistent. In addition, patients who are health illiterate cannot understand critical information about the management of their own care and well-being.
3. Diagnostic errors, management of test results
   Definition: Errors in diagnosis, medication, and communication/management of test results on behalf of the provider can have serious patient safety consequences. Reporting such errors is critical to ensuring patient safety and provider accountability.
4. Medication prescription, management, drug interactions, adherence
   Definition: Medication management on behalf of the patient is often a safety issue when patients do not correctly manage their medications or adhere to treatment guidelines.
5. Antibiotic, opioid, and other medication overuse
   Definition: The overuse of antibiotics and opioids can pose long-term safety consequences for the individual as well as the community in terms of antibiotic resistance and opioid addiction.

Safety Solutions

1. Care team models, including expanded care teams
   Definition: Collaborative teams of providers work together to integrate new models of care to combat fragmentation, particularly with pharmacists.
2. Medication lists, reconciliation, programs to enhance adherence
   Definition: Health information technology can include mobile messaging, telemedicine, electronic health records, etc., to improve communication between patients and providers and exchange of critical health information.
3. Patient and family advisory councils, boards, committees
   Definition: A group consisting of patients, providers, and practice or hospital staff and/or administrators engaged together to improve the function, structure, and processes of the health care organization.
4. Educational interventions
   Definition: Educational interventions seek to fill in knowledge gaps for patients about critical aspects of the care, including (but not limited to) information about diagnosis, treatment, prevention, and illness self-management.
5. Shared decisionmaking models
   Definition: A shared decisionmaking model prompts the provider and patient to share available evidence in order to make an informed decision together that best fits the patient’s needs and preferences.
6. Family engagement in patient care (patient engagement is a given)
   Definition: Family engagement in patient care occurs when families are prompted by health care providers to engage to provide additional support, particularly when it comes to treatment adherence and prevention.