Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care
Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care
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DOI：
10.1371/journal.pone.0128329
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发表时间：
2015-08-05
期刊：
影响因子：
3.7
通讯作者：
Sanders, Caroline
中科院分区：
文献类型：
--
作者：
Daker-White, Gavin;Hays, Rebecca;Sanders, Caroline
目的卫生保健中对患者安全的研究传统上集中在医院医学上。然而，近年来，更多的研究集中在初级保健环境中，与二级保健相比具有不同的特点。本研究旨在综合已发表的有关初级保健患者安全性的定性研究，以建立概念模型。方法元人种志，一种解释性综合方法，其产生的三阶解释最好地描述了初级研究报告中包含的一组发现。结果48项研究包括5个独立的子集，这些研究结果相互转换：患者的安全观点、工作人员的安全观点、用药安全、系统或组织问题以及初级/二级保健界面。这些研究主要集中在可以改善或损害患者安全的问题上。这些问题涉及患者、工作人员或临床系统的特征或行为，以及工作人员、患者和工作人员之间的互动，或人员和系统之间的互动。可以看到，电子健康记录、协议和指南在不同的情况下既降低了患者的安全，又提高了患者的安全。对这些研究的概念性解读指出，患者安全是一种基于道德观点的主观感觉或判断，并具有潜在的隐藏心理后果，影响护理过程和关系。对安全的主要威胁似乎来自“重大”系统问题，例如涉及服务可获得性、资源或工作时间的问题，这些问题可能无法得到个人实践或卫生工作者的有效干预，特别是在公共卫生系统的背景下。结论总体而言，这些发现强调了患者安全初级卫生保健中的人的因素。病人安全的关键在于病人与医护人员之间或参与个别病人护理的不同医护人员之间的有效面对面沟通。当电子系统忽略了面对面交流的机会时，它们可能会危及安全。指南或协议被认为损害或改善患者安全的情况需要进一步调查。
ObjectiveStudies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.MethodMeta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.ResultsForty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients' perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from 'grand' systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.ConclusionOverall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.