title: MAXimising Involvement in MUltiMorbidity (MAXIMUM) in primary care: protocol for an observation and interview study of patients, GPs and other care providers to identify ways of reducing patient safety failures.
abstract: BACKGROUND
  Increasing numbers of older people are living with multiple long-term health conditions but global healthcare systems and clinical guidelines have traditionally focused on the management of single conditions. Having two or more long-term conditions, or 'multimorbidity', is associated with a range of adverse consequences and poor outcomes and could put patients at increased risk of safety failures. Traditionally, most research into patient safety failures has explored hospital or inpatient settings. Much less is known about patient safety failures in primary care. Our core aims are to understand the mechanisms by which multimorbidity leads to safety failures, to explore the different ways in which patients and services respond (or fail to respond), and to identify opportunities for intervention.
  
  
  METHODS
  We plan to undertake an applied ethnographic study of patients with multimorbidity. Patients' interactions and environments, relevant to their healthcare, will be studied through observations, diary methods and semistructured interviews. A framework, based on previous studies, will be used to organise the collection and analysis of field notes, observations and other qualitative data. This framework includes the domains: access breakdowns, communication breakdowns, continuity of care errors, relationship breakdowns and technical errors.
  
  
  BACKGROUND
  Ethical approval was received from the National Health Service Research Ethics Committee for Wales. An individual case study approach is likely to be most fruitful for exploring the mechanisms by which multimorbidity leads to safety failures. A longitudinal and multiperspective approach will allow for the constant comparison of patient, carer and healthcare worker expectations and experiences related to the provision, integration and management of complex care. This data will be used to explore ways of engaging patients and carers more in their own care using shared decision-making, patient empowerment or other relevant models.
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK.
authors.forename: Gavin
authors.initials: G
authors.lastname: Daker-White
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hays
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK.
authors.forename: Aneez
authors.initials: A
authors.lastname: Esmail
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK.
authors.forename: Brian
authors.initials: B
authors.lastname: Minor
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre (Greater Manchester PSTRC), University of Manchester, Manchester, UK.
authors.forename: Wendy
authors.initials: W
authors.lastname: Barlow
authors.affiliation: Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Brown
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Blakeman
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
mesh_terms: D003142:Communication; D015897:Comorbidity; D003266:Continuity of Patient Care; D006297:Health Services Accessibility; D006801:Humans; D019300:Medical Errors; D061214:Patient Safety; D010817:Physician-Patient Relations; D011320:Primary Health Care / Q000379:methods*; D058996:Quality Improvement; D006113:United Kingdom
keywords: QUALITATIVE RESEARCH