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Research ArticleOriginal Research

Patient Reports of Preventable Problems and Harms in Primary Health Care

Anton J. Kuzel, Steven H. Woolf, Valerie J. Gilchrist, John D. Engel, Thomas A. LaVeist, Charles Vincent and Richard M. Frankel
The Annals of Family Medicine July 2004, 2 (4) 333-340; DOI: https://doi.org/10.1370/afm.220
Anton J. Kuzel
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Steven H. Woolf
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Valerie J. Gilchrist
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John D. Engel
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Thomas A. LaVeist
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Charles Vincent
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Richard M. Frankel
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    Figure 1.

    Problems throughout the process of care.

    * Typology codes:

    1. Access breakdown, difficulty contacting office, involving telephone system, telephone not answered, and excessive time on hold.

    2. Relationship breakdown, intermediary imposed on communication with clinician; and access breakdown, no return of telephone call.

    3. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, rude behavior.

    4. Inefficiency of care, duplicative registration.

    5. Access breakdown, excessive office waiting time.

    6. Relationship breakdown, disrespect or insensitivity, evident in patient flow in the office, prioritizing patients based on race.

    7. Relationship breakdown, inadequate time with provider.

    8. Technical error, deficiency in history, incomplete history of medications.

    9. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient advice ignored.

    10. Technical error, deficiency in treatment or follow-up, results of investigations not shared with patient.

    11. Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient preferences not respected.

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    Table 1.

    Unique Events Associated With Preventable Harms (N = 221), by Taxonomy Order

    Number of Unique Reports
    Unique Events1st2nd3rd
    Note: taxonomy is ordered from general to specific. Coding actually went to a fourth order of specificity; 3 orders are shown.
    1. Access breakdown63
        1.1. Difficulty initiating contact with office by telephone10
        1.2. Excessive delay in obtaining appointment with clinician10
        1.3. Excessive delay in obtaining referral to specialist1
        1.4. Excessive delay in / no return of telephone call7
        1.5. Excessive office waiting time17
        1.6. Service not covered11
        1.6.1. Medications not covered2
        1.6.2. Family member excluded from practice1
        1.6.3. Specialty services limited8
        1.7. Service not available7
        1.7.1. Lack of telephone care4
        1.7.2. Lack of acute care2
        1.7.3. Lack of evaluation before referral1
    2. Communication breakdown17
        2.1. Within office8
        2.1.1. Insurance information not recorded1
        2.1.2. Insurance information not updated1
        2.1.3. Payment not posted1
        2.1.4. Appointment improperly scheduled3
        2.1.5. Wrong chart used for patient2
        2.2. Between office and outside entity other than patient9
        2.2.1. Referrals not done4
        2.2.2. Improper coding of service1
        2.2.3. Medication refill not called to pharmacy2
        2.2.4. Records not transferred to requesting clinician2
    3. Relationship breakdown82
        3.1. Inadequate time with clinician9
        3.2. Intermediary imposed on communication with clinician6
        3.3. Care by other than usual clinician4
        3.4. Disrespect or insensitivity63
        3.4.1. Evident in interpersonal communication38
        3.4.2. Evident in patient flow in office20
        3.4.3. Evident in office environment5
    4. Technical error54
        4.1. Deficiency in history4
        4.1.1. Incomplete history of present illness2
        4.1.2. Incomplete history of medications1
        4.1.3. Incomplete past history1
        4.2. Deficiency in physical examination1
        4.2.1. Incomplete physical examination1
        4.3. Deficiency in investigations1
        4.3.1. Artifact introduced in x-ray1
        4.4. Deficiency in diagnosis11
        4.4.1. Failure to appreciate severity/acuity of problem1
        4.4.2. Wrong diagnosis4
        4.4.3. Dismissing selected symptoms2
        4.4.3. Perceived failure to make any diagnosis4
        4.5. Deficiency in treatment and follow up35
        4.5.1. Poor injection technique1
        4.5.2. Results of investigations not shared with patient6
        4.5.3. Inadequate patient education reprocedure, diagnosis or treatment18
        4.5.4. Premature recommendation for hysterectomy1
        4.5.5. Perceived polypharmacy1
        4.5.6. Wrong medication dose2
        4.5.7. No treatment for pain2
        4.5.8. Inadequate follow up care4
        4.6. Deficiency in business practice2
        4.6.1. Requiring patient to pay before insurance company1
        4.6.2. Balance billing by participating clinician1
    5. Inefficiency of care5
        5.1. Excessive data elements for registration1
        5.2. Duplicative registration2
        5.3. Unnecessary office visit2
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    Table 2.

    Preventable Harms (N = 170) Reported by Respondents, by Number of Unique Instances

    HarmNumber
    Psychological119
    Anger and related emotions
        Anger31
        Upset8
        Irritated4
        Frustrated17
    Personal worth
        Belittled15
        Sense of violation3
        Sense of betrayal1
    Relationship effects
        Diminished trust in clinician11
        Diminished relationship with clinician7
        Anxiety about health10
    Related to opportunity cost
        Wasted time6
        Anxiety about other responsibilities2
        Anxiety about bills2
        Forget important issue
    Other emotions
        Disappointed1
        Confused1
        Mood swing1
    Physical39
    Pain
        Not otherwise specified12
        Abdominal pain2
        Low back pain1
        Bruising4
    Related to medication effects
        Hypoglycemia2
        Somnolence1
        Drug interactions1
    Worsening problem
        Asthma3
        Hypertension1
        Cellulitis1
        Flank abscess1
        Uterine bleeding1
    Undertreated, untreated conditions
        Hyperlipidemia1
        Diabetes1
        Sjögren’s syndrome1
    Other
        Weakness2
    “Sick”2
        Dizziness1
        Fever1
    Economic, other12
    Avoidable personal medical expense9
    Threat to credit rating1
    Lost work time, pay1
    End of sports career1

Additional Files

  • Figures
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  • Supplemental Appendix

    Additional Illustrative Quotes Assembled by Steven H. Woolf, MD, MPH

    Files in this Data Supplement:

    • Supplemental data: Appendix - PDF file, 8 pages, .23 MB
  • The Article in Brief

    Thirty-eight patients were interviewed about problems they experienced in the primary care office setting. Most of the problems they identified related to difficulties in their relationships with doctors or others in the medical office (for example, many felt that they were treated with disrespect or insensitivity), or problems in getting access to the doctor or the office (such as delays in getting appointments or long waiting times). Patients described more psychological and emotional harms than physical harms.

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The Annals of Family Medicine: 2 (4)
The Annals of Family Medicine: 2 (4)
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1 Jul 2004
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Patient Reports of Preventable Problems and Harms in Primary Health Care
Anton J. Kuzel, Steven H. Woolf, Valerie J. Gilchrist, John D. Engel, Thomas A. LaVeist, Charles Vincent, Richard M. Frankel
The Annals of Family Medicine Jul 2004, 2 (4) 333-340; DOI: 10.1370/afm.220

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Patient Reports of Preventable Problems and Harms in Primary Health Care
Anton J. Kuzel, Steven H. Woolf, Valerie J. Gilchrist, John D. Engel, Thomas A. LaVeist, Charles Vincent, Richard M. Frankel
The Annals of Family Medicine Jul 2004, 2 (4) 333-340; DOI: 10.1370/afm.220
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