Exploring patient safety in rural general practice - a mixed-methods approach

Abstract

<p>Unsafe medical practices and incidents where safety hazards cause harm to patients occur daily in general practice. The costs to society, health care personnel and individual patients are substantial and deserve attention. “Hazards” can be regarded as local error-producing factors, latent failures, which create conditions for unsafe medical practice to take place. “Harm” occurs when these conditions breach safety barriers and reach the patients. Individual doctors who make mistakes created by these factors are most likely to continue to make mistakes until the underlying conditions are remedied. The responsibility for establishing safety barriers in healthcare systems is assigned to health professionals, health organisations and the government. In Norway, there is a general practitioner (GP) scheme involving more than 4700 doctors at present. It includes a patient list system that enables the care of individuals over time, i.e. continuity of care. Continuity varies between municipalities in Norway. In small municipalities, the GP scheme is affected by the frequent use of locums (substitute GPs). Rural GP clinics also face challenges in care provision in terms of vast transportation distances and possible support of secondary care specialists. Little is known about patient safety threats in these clinics, which is the basis for my research for this doctoral dissertation. <p>In the first study we interviewed rural general practice patients and in the third study GPs and other health care personnel. In these studies we asked about their experiences with hazards, harm, patient safety incidents and low quality of care. The second study was a quantitative analysis of disciplinary actions against doctors in Norway in 2011-2018. The doctoral dissertation is based on a mixed-method approach to analyse these results in combination. <p>In paper I and III the participants described many different safety hazards and harm. In paper I patients coped with these conditions by accepting, confronting or planful problem-solving. In paper III the rural general practice staff described how vulnerability for patient safety incidents were linked to frequent use of locums, work overload and contextual factors like bad weather and distance to hospitals. The personnel used knowledge of local context and an awareness to risk of error to hinder patient safety incidents. Results from paper II showed that primary care doctors got 8 times more disciplinary actions than hospital doctors. Rural GPs got relatively most disciplinary actions, 1.7 times more compared to urban GPs. <p>To perform a scientific analysis of qualitative and quantitative results, I have used pragmatism as a theory of science and a mixed-methods design. In brief, this means transforming the quantitative results in Paper II into narrative descriptions. These descriptions are then jointly analysed with the results from Papers I and III. The analysis shows that safety hazards and harm in rural general practice are diverse and seem to occur nation-wide. The causes of harm are both individual and system safety hazards such as frequent use of locum GPs, lack of continuity of care, long distances and high workload. Patients, health care personnel, and the Norwegian Board of Health Supervision (NBHS) are aware of this. Harming patients in rural areas is likely to continue. However, health care workers and patients both help to reduce risks through an awareness of potential safety hazards, the use of local contextual knowledge and confronting errors, especially those made by locum GPs. The method of risk reduction used by the NBHS is system-based by taking disciplinary action against individual doctors based on individual behaviour. <p>Incentives and initiatives from local and national health care leaders to address the safety issues mentioned here and develop safer health care are needed. Greater insight into patient safety in general practice can be revealed through future qualitative, quantitative and mixed-methods studies.

Utrygg medisinsk praksis som skader pasienter, forekommer daglig i allmennpraksis. Helsetjenesten i distrikt er påvirket av store reiseavstander for pasientene til legekontoret, og til spesialisthelsetjenesten på sykehus. Lite er imidlertid kjent om pasientsikkerheten ved slike legekontor i distrikt. Vi intervjuet pasienter, og deretter fastleger og helsepersonell som alle bor og jobber i distrikt. Vi har undersøkt deres erfaringer med uheldige hendelser, utrygg medisinsk praksis, pasientskader og lav kvalitet på helseomsorgen. Vi har også gjort en kvantitativ analyse av administrative reaksjoner gitt norske leger mellom 2011-2018. Doktorgraden baserer seg på en mixed-methods tilnærming til disse resultatene. Uheldige hendelser og utrygg medisinsk praksis ved distriktslegekontor er varierte og forekommer antakelig over hele landet. Hyppig bruk av vikarleger, manglende kontinuitet, lang reiseavstand og høy arbeidsbelastning er alle mulige risikofaktorer. Basert på indikasjoner fra trendanalysene, vil skade av pasienter på legekontor i distrikt sannsynligvis fortsette å skje i fremtiden. Flere insentiver og initiativ fra lokale og nasjonale myndigheter trengs for å bedre pasientsikkerheten. Gjennom kvalitativ, kvantitativ og mixed-methods forskning kan man øke forståelsen og bedre kunnskapen om pasientsikkerhet på legekontor i distrikt.