Primary Care Interventions to Improve Medication Safety – A Qualitative Study

Context: Many sources state that patients are frequently harmed by lapses in primary care medication safety.

Objective: We investigated beliefs and actions taken by primary care physicians (PCPs) and their teams to improve medication safety.

Study Design and Analysis: Semi-structured interviews analyzed using grounded theory.

Setting: Four primary care sites in Texas.

Population: Family physicians, family medicine residents, nurses, and medical assistants (n=21 total).

Instrument: Study-specific interview guide.

Outcomes: Concrete examples and new theoretical insights about primary care medication safety.

Results: We identified 132 distinct primary care work system strategies to improve medication safety. PCPs and their teams believe that medication safety is an important responsibility of all team members, and is expressed through patient shared decision making, medical decision making independent of patient input, educating patients and their caregivers, providing clinical infrastructure, and providing asynchronous care separate from an office visit. Major actions taken by PCP teams reflected many key principles of high reliability organizations, such as sensitivity to operations, reluctance to simplify, and commitment to resilience. PCP teams interact with many other agents in the complex healthcare system that they cannot control, but they must respond to, using logic of anticipation and logic of resilience. Medication safety in primary care is realized through actions taken by front-line caregivers with customized processes and resources; such as adjusting medications in response to insurance company formulary changes, writing out instructions in non-English languages, and deviating from simplistic single-disease guidelines in response to patient-specific co-morbidities or preferences; rather than a top-down command-control algorithm-driven approach to care. PCP teams work within open or distributed work systems, rather than the closed systems of previous healthcare safety exemplars such as hospital surgical or inpatient environments. Compared to closed systems, many of the root cause safety events are not within the primary care work system’s control.

Conclusions: PCP teams improve medication safety through anticipatory and resilient responses to many external forces coming from open systems they cannot control.