Article Figures & Data
Figures
- Figure 1.
Problems throughout the process of care.
* Typology codes:
Access breakdown, difficulty contacting office, involving telephone system, telephone not answered, and excessive time on hold.
Relationship breakdown, intermediary imposed on communication with clinician; and access breakdown, no return of telephone call.
Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, rude behavior.
Inefficiency of care, duplicative registration.
Access breakdown, excessive office waiting time.
Relationship breakdown, disrespect or insensitivity, evident in patient flow in the office, prioritizing patients based on race.
Relationship breakdown, inadequate time with provider.
Technical error, deficiency in history, incomplete history of medications.
Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient advice ignored.
Technical error, deficiency in treatment or follow-up, results of investigations not shared with patient.
Relationship breakdown, disrespect or insensitivity, evident in interpersonal communication, patient preferences not respected.
Tables
Number of Unique Reports Unique Events 1st 2nd 3rd Note: taxonomy is ordered from general to specific. Coding actually went to a fourth order of specificity; 3 orders are shown. 1. Access breakdown 63 1.1. Difficulty initiating contact with office by telephone 10 1.2. Excessive delay in obtaining appointment with clinician 10 1.3. Excessive delay in obtaining referral to specialist 1 1.4. Excessive delay in / no return of telephone call 7 1.5. Excessive office waiting time 17 1.6. Service not covered 11 1.6.1. Medications not covered 2 1.6.2. Family member excluded from practice 1 1.6.3. Specialty services limited 8 1.7. Service not available 7 1.7.1. Lack of telephone care 4 1.7.2. Lack of acute care 2 1.7.3. Lack of evaluation before referral 1 2. Communication breakdown 17 2.1. Within office 8 2.1.1. Insurance information not recorded 1 2.1.2. Insurance information not updated 1 2.1.3. Payment not posted 1 2.1.4. Appointment improperly scheduled 3 2.1.5. Wrong chart used for patient 2 2.2. Between office and outside entity other than patient 9 2.2.1. Referrals not done 4 2.2.2. Improper coding of service 1 2.2.3. Medication refill not called to pharmacy 2 2.2.4. Records not transferred to requesting clinician 2 3. Relationship breakdown 82 3.1. Inadequate time with clinician 9 3.2. Intermediary imposed on communication with clinician 6 3.3. Care by other than usual clinician 4 3.4. Disrespect or insensitivity 63 3.4.1. Evident in interpersonal communication 38 3.4.2. Evident in patient flow in office 20 3.4.3. Evident in office environment 5 4. Technical error 54 4.1. Deficiency in history 4 4.1.1. Incomplete history of present illness 2 4.1.2. Incomplete history of medications 1 4.1.3. Incomplete past history 1 4.2. Deficiency in physical examination 1 4.2.1. Incomplete physical examination 1 4.3. Deficiency in investigations 1 4.3.1. Artifact introduced in x-ray 1 4.4. Deficiency in diagnosis 11 4.4.1. Failure to appreciate severity/acuity of problem 1 4.4.2. Wrong diagnosis 4 4.4.3. Dismissing selected symptoms 2 4.4.3. Perceived failure to make any diagnosis 4 4.5. Deficiency in treatment and follow up 35 4.5.1. Poor injection technique 1 4.5.2. Results of investigations not shared with patient 6 4.5.3. Inadequate patient education reprocedure, diagnosis or treatment 18 4.5.4. Premature recommendation for hysterectomy 1 4.5.5. Perceived polypharmacy 1 4.5.6. Wrong medication dose 2 4.5.7. No treatment for pain 2 4.5.8. Inadequate follow up care 4 4.6. Deficiency in business practice 2 4.6.1. Requiring patient to pay before insurance company 1 4.6.2. Balance billing by participating clinician 1 5. Inefficiency of care 5 5.1. Excessive data elements for registration 1 5.2. Duplicative registration 2 5.3. Unnecessary office visit 2 - Table 2.
Preventable Harms (N = 170) Reported by Respondents, by Number of Unique Instances
Harm Number Psychological 119 Anger and related emotions Anger 31 Upset 8 Irritated 4 Frustrated 17 Personal worth Belittled 15 Sense of violation 3 Sense of betrayal 1 Relationship effects Diminished trust in clinician 11 Diminished relationship with clinician 7 Anxiety about health 10 Related to opportunity cost Wasted time 6 Anxiety about other responsibilities 2 Anxiety about bills 2 Forget important issue Other emotions Disappointed 1 Confused 1 Mood swing 1 Physical 39 Pain Not otherwise specified 12 Abdominal pain 2 Low back pain 1 Bruising 4 Related to medication effects Hypoglycemia 2 Somnolence 1 Drug interactions 1 Worsening problem Asthma 3 Hypertension 1 Cellulitis 1 Flank abscess 1 Uterine bleeding 1 Undertreated, untreated conditions Hyperlipidemia 1 Diabetes 1 Sjögren’s syndrome 1 Other Weakness 2 “Sick” 2 Dizziness 1 Fever 1 Economic, other 12 Avoidable personal medical expense 9 Threat to credit rating 1 Lost work time, pay 1 End of sports career 1
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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