Patient safety aims to prevent and reduce the potential risks, errors, and harms to patients that can occur during the provision of health care. 55 Threats to patient safety in primary care settings include diagnostic errors or delays; medication errors, including inappropriate or overprescribing; breakdowns in communication between clinicians and patients and families, or within clinical teams; and fragmentation of care. 56 In addition, many primary care patients continue to receive referrals for low-value screenings and tests that have been shown to have high rates of false-positive results. 57 This can set off a cascade of patient harms including anxiety, financial burden, and unnecessary treatments which can have their own physical harms. However, primary care also plays an important role in reducing common patient harms, such as preventing avoidable hospital admissions and readmissions. 58 As described in AHRQ’s Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families, the strong and trusting relationships forged in primary care through patient and family engagement are essential for ensuring that care is safe and effective. 59
AHRQ has funded many primary care grants related to patient safety as well as several patient safety resources for the primary care or ambulatory care setting, as described below.
Grants with a focus on health equity are indicated with this icon.
A total of 30 AHRQ primary care grants funded in FYs 2021 and 2022 look at issues of patient safety, including reducing diagnostic errors, improving medication management, and antibiotic stewardship. All but three of these grants also had another topic focus and are described in other sections of this report [Practice and Quality Improvement (12), Digital Healthcare (9), Person-Centered Care (3), Behavioral Health and Substance Use Disorders (1), and Health Equity (1), and Primary Care Workforce (1)]. The three patient safety grants not already described in the key topic area sections are described in the table below, including two R18s (Research Demonstration and Dissemination Projects) and one R01 (Research Project). A full table of the 30 primary care grants with a focus on patient safety is included in Appendix C: Patient Safety.
PI: Mark Herbert Ebell
Organization: University of Georgia; Public Health and Preventive Medicine
This observational study collects and examines data on the clinical presentation, evaluation, management, and outcomes for 1400 patients with lower respiratory tract infections. The research team will use the findings to develop tools primary care clinicians can use to effectively identify patients who are likely to have an uncomplicated treatment course. The goal is to help reduce inappropriate antibiotic prescriptions and the related costs and harms of inappropriate antibiotic use.
PI: Joshua J Fenton
Organization: University of California at Davis; Internal Medicine
Refines and evaluates a simulated intervention, which uses actors playing patients, to teach primary care physicians to build skills recommending watchful waiting to patients who request low-value and potentially harmful imaging for low back pain. This study has the potential to develop useful communication strategies that primary care physicians can use to steer patients away from potentially harmful testing while maintaining the patient-doctor relationship.
PI: Alok Kapoor
Organization: University of Massachusetts, Medical School Worcester; Internal Medicine
A multidisciplinary nonprofit organization recently published the direct oral anticoagulants (DOAC) Checklist for Optimal Care Transitions to elaborate the steps required to ensure a safe transition of care in ambulatory venous thromboembolism (VTE) patients. This project operationalizes the items of the Checklist to create a comprehensive care transition intervention that can be delivered by clinical pharmacists and a pharmacy technician. The care transition intervention will have the potential to prevent DOAC-related medication errors, improve the quality of care during care transitions, and increase patient knowledge and medication adherence.
The Center for Quality Improvement and Patient Safety (CQuIPS) is the organizational center within AHRQ that works to improve the quality and safety of health care, and includes several AHRQ programs. 60
While the focus of AHRQ’s patient safety programs and initiatives are broader than primary care, there are several recent resources that are primary care specific, which are described below. Additional AHRQ patient safety initiatives and resources can be found on AHRQ’s website, including the Making Healthcare Safer III report, as well as several resources that are tailored specifically for the ambulatory care setting.
AHRQ's HAI program funds research and implementation projects that advance the science of HAI prevention, develop more effective approaches for reducing HAIs, and help frontline clinicians better understand how to apply proven methods to make care safer. 61
AHRQ’s PSNet is a searchable database of resources related to patient safety across healthcare settings. PSNet content includes publications, perspectives, innovations, toolkits, primers, trainings, and events—and can be searched using keywords and filters to narrow your results. A few examples of primary care relevant content from 2021 and 2022 on PSNET include:
AHRQ’s PSO program oversees the listing process for PSOs, development and maintenance of the AHRQ Common Formats and the network of patient safety databases, and provides technical assistance to PSOs, providers and the public.(62)
This guide walks clinicians through steps and exercises to help them evaluate and improve their diagnostic performance. This guide is meant for all clinicians whose practice includes diagnosis, including primary care clinicians.
These principles were developed based on overarching concepts primary care practices can incorporate into their strategic management to help reduce hospital readmissions. The ways these are applied vary based on practices’ patient population and resources, as well as other relevant local factors.
