Patients' concerns about medical errors during hospitalization

A meta-analysis of idiopathic granulomatous mastitis treatments for remission and recurrence prevention

Purpose

The major aim of our meta-analysis was to review the effectiveness of various treatment modalities for achieving successful remission and preventing recurrence for women with idiopathic granulomatous mastitis (IGM). This knowledge is instrumental in developing evidence-based guidelines for clinicians to improve management strategies and outcomes for patients with IGM.

Methods

A systematic literature search was performed on MEDLINE (Ovid), Embase (Elsevier), PubMed, Cochrane Library, Web of Science, and Google Scholar; studies published to 19 January 2022 were included. A meta-analysis of 57 observational studies was performed. The results of two randomized controlled trials were also examined.

Results

There were 3,035 IGM patients across the observational and randomised studies. Overall recurrence and remission rates across all treatment strategies in 59 studies are 87.9% (2,667/3035) and 13.5% (359/2667), respectively. The studies reported 19 different treatment strategies, comprising observation, medical monotherapies, surgery, and combinations involving medical therapies, with and without surgery. Among monotherapy treatment, surgical management had the highest pooled remission rate (0.99 [95% confidence interval (CI) = 0.97-1.00]); among combination therapy, this was steroids and surgery (0.99 [0.94-1.00]). Antibiotic monotherapy had the lowest remission rate (0.72 [0.37-0.96]). The highest recurrence rates belonged to treatments that combined antibiotics and surgery (0.54 [0.02-1.00]), and antibiotics, steroids, and surgery (0.57 [0.00-1.00]). Most successful for preventing recurrence were observation (0.03 [0.00-0.10]), methotrexate (0.08 [0.00-0.24]), and steroids and surgery (0.05 [0.01-0.12]). There is a significant association between longer follow-up duration and recurrence rate reported, p = 0.002.

Conclusion

Combination therapies, especially those incorporating antibiotics, steroids, and surgery, have demonstrated higher remission rates, challenging the use of antibiotic monotherapy. There is an increased emphasis on the need for personalised, multi-pronged approach for preventing IGM recurrence, with longer follow-up care. More prospective future work in IGM research, with standardised diagnostic criteria, treatment protocols, and reporting guidelines will be important for developing treatment protocols and guidelines clinicians can adhere to in the clinical management of IGM patients.Systematic review registration: PROSPERO (CRD42022301386).

Parent Experiences with the Process of Sharing Inpatient Safety Concerns for Children with Medical Complexity: A Qualitative Analysis

OBJECTIVE

To describe the process of identifying and reporting inpatient safety concerns from the perspective of parents of children with medical complexity (CMC).

METHODS

We conducted a secondary analysis of qualitative data from semi-structured interviews with 31 English and Spanish-speaking parents of CMC at two tertiary children's hospitals. Interviews lasted 45-60 minutes and were audio-recorded, translated, and transcribed. Three researchers inductively and deductively coded transcripts using an iteratively refined codebook with validation by a fourth researcher. Thematic analysis was used to develop a conceptual model of the process of inpatient parent safety reporting.

RESULTS

We identified four steps illustrating the process of inpatient parent safety concern reporting 1) parent recognizing concern, 2) parent reporting concern, 3) staff/hospital response continuum, and 4) parent feelings of validation/invalidation. Many parents endorsed that they were the first to catch a safety concern and were identified as unique reporters of safety information. Parents typically described reporting their concerns verbally and in real-time to the person they felt could quickly remedy the situation. There was a spectrum of validation. Some parents reported their concerns were not acknowledged and addressed, which led them to feel overlooked, disregarded, or judged. Others reported their concerns were acknowledged and addressed, resulting in parents feeling heard and seen and often leading to changes in clinical care.

CONCLUSIONS

Parents described a multi-step process of reporting safety concerns during hospitalization and a spectrum of staff response and validation. These findings can inform family-centered interventions that support safety concern reporting in the inpatient setting.

More than medications: a patient-centered assessment of Parkinson's disease care needs during hospitalization

Background

Parkinson's disease (PD) increases the risk of hospitalization and complications while in the hospital. Patient-centered care emphasizes active participation of patients in decision-making and has been found to improve satisfaction with care. Engaging in discussion and capturing hospitalization experience of a person with PD (PwP) and their family care partner (CP) is a critical step toward the development of quality improvement initiatives tailored to the unique hospitalization needs of PD population.

Objectives

This qualitative study aimed to identify the challenges and opportunities for PD patient-centered care in hospital setting.

Methods

Focus groups were held with PwPs and CPs to capture first-hand perspectives and generate consensus themes on PD care during hospitalization. A semi-structured guide for focus group discussions included questions about inpatient experiences and interactions with the health system and the clinical team. The data were analyzed using inductive thematic analysis.

Results

A total of 12 PwPs and 13 CPs participated in seven focus groups. Participants were 52% female and 28% non-white; 84% discussed unplanned hospitalizations. This paper focuses on two specific categories that emerged from the data analysis. The first category explored the impact of PD diagnosis on the hospital experience, specifically during planned and unplanned hospitalizations. The second category delves into the unique needs of PwPs and CPs during hospitalization, which included the importance of proper PD medication management, the need for improved hospital ambulation protocols, and the creation of disability informed hospital environment specific for PD.

Conclusion

PD diagnosis impacts the care experience, regardless of the reason for hospitalization. While provision of PD medications was a challenge during hospitalization, participants also desired flexibility in ambulation protocols and an environment that accommodated their disability. These findings highlight the importance of integrating the perspectives of PwPs and CPs when targeting patient-centered interventions to improve hospital experiences and outcomes.

How do National Health Service (NHS) organisations respond to patient concerns? A qualitative interview study of the Patient Advice and Liaison Service (PALS)

OBJECTIVES

To describe the current work of the Patient Advice and Liaison Service (PALS) and assess the service's potential to resolve concerns and contribute to organisational learning.

DESIGN

A qualitative study using semistructured interviews.

SETTING

Four mental health trusts and four acute trusts in the English National Health Service, a total of eight PALS across different trusts.

PARTICIPANTS

Twenty-four participants comprising of PALS staff and clinicians working with PALS teams.

METHODS

Semistructured interviews were undertaken with participants using video conferencing software. The framework method was used for the analysis of the large qualitative dataset, which is a conventional method of analysis, similar to thematic or qualitative content analysis.

RESULTS

PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving a variety of recurrent problems, including PALS staff communication, staff attitudes and waiting times. The remit and responsibilities of each PALS has often broadened over time. Barriers to resolving concerns included a lack of awareness of PALS, limited to no policies informing how staff resolve concerns, an emphasis on complaints and the attitude of clinical staff. Senior management had widely differing views on how the PALS should operate and the management of complaints is a much higher priority. Few PALS teams carried out any analysis of the data or shared data within their organisations.

CONCLUSIONS

PALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving concerns. PALS staff also act as navigators of services, mediators between families and staff and, occasionally, patient advocates in supporting them to raise concerns. PALS has the potential to reduce complaints, increase patient satisfaction and provide rapid organisational feedback. Achieving this potential will require more awareness and support within organisations together with updated national policy guidance.

Nurses' Decisions in Error Reporting and Disclosing Based on Error Scenarios: A Mixed-method Study

Background: It is ensured that nurses’ error reporting and disclosing improve services to patients and are considered a movement toward creating a culture of transparency in the healthcare system. Objectives: This study aimed to investigate the nurses' decisions on reporting and disclosing Medical Errors (MEs). Methods: This research followed a mixed-method embedded design that was performed in five hospitals in Iran in 2018. A total of 491 nurses participated in the quantitative phase of the study with stratified sampling, followed by a simple random sampling technique. Also, 22 nurses joined the qualitative phase. Data were collected using a researcher-made questionnaire and semi-structured interviews through a scenario-based method. Quantitative data analysis was performed using descriptive and analytical statistics by SPSS 21.0 and Expert Choice 10.0 software. The qualitative data were analyzed based on the content analysis approach. Results: The most important perceived barriers with the highest impact coincided with educational (57.17%) and motivational (56.77%) factors based on SEM analysis (ES: 1.33, SE: 0.16). Regression analysis showed that error-reporting mechanisms, educational factors, and reporting consequences were significantly associated with age, sex, and work experience (P-Value ≤0.05). Error scenarios were thematized into three categories: Error perception (including ambiguity and weakness in error definition, the severity of the error, unawareness of guidelines, deviation from standards, and untrained staff), error reporting (including ineffective reporting system, hesitation in reporting to a formal system, increased workload, improper reaction, punitive responses, and concerns about consequences), and error disclosure (including no disclosure, partial disclosure, and full disclosure). Conclusions: The obtained results contributed to a better understanding of the barriers to error reporting and disclosing. In addition, these results can help hospitals encourage error reporting and ultimately make organizational changes, which reduce the incidence of errors.

Nurse Sensemaking for Responding to Patient and Family Safety Concerns

BACKGROUND

Hospitals need to prevent, respond to, and learn from safety risks and events perceived by patients and families, who in turn rely on nurses to respond to and report their safety concerns.

OBJECTIVES

The aim of the study was to describe the process by which bedside nurses evaluate and determine the appropriate response to safety concerns expressed by patients or their families.

METHODS

A qualitative design was employed. We recruited inpatient bedside nurses in an 811-bed Midwest academic medical center. Nurses provided demographic information and participated in semistructured interviews designed to elicit narratives related to evaluation and response to patient- or family-expressed safety concerns. Data analysis and interpretation were guided by grounded theory.

RESULTS

We enrolled 25 nurses representing 22 units. Based on these nurses' experiences, we developed a grounded theory explaining how nurses evaluate a patient or family safety concern. Nurses make sense of the patient's or family's safety concern in order to take action. Achieving this goal requires evaluation of the meaningfulness and reasonableness of the concern, as well as the potential effect of the concern on the patient. Based on this nursing evaluation, nurses respond in ways designed to (a) manage emotions, (b) immediately resolve concerns, (c) involve other team members, and (d) address fear or uncertain grounding in reality. Nurses reported routinely handling safety concerns at the bedside without use of incident reporting.

DISCUSSION

Safety requires an interpersonal and evaluative nursing process with actions responsive to patient and family concerns. Safety interventions designed to be used by nurses should be developed with the dynamic, cognitive, sensemaking nature of nurses' routine safety work in mind. Being sensitive to the vulnerability of patients, respecting patient and family input, and understanding the consequences of dismissing patient and family safety concerns are critical to making sense of the situation and taking appropriate action to maintain safety. Measuring patient safety or planning improvement based on patient or family expression of safety concerns would be a difficult undertaking using only standard approaches. A more complex approach incorporating direct patient engagement in data collection is necessary to gain a complete safety picture.

A grounded theory of creating space for open safety communication between hospitalized patients and nurses

BACKGROUND

There is evidence that fear of negative nurse response may prevent hospitalized patients from sharing safety concerns, adversely affecting patient safety.

PURPOSE

The purpose of the present study was to describe the process by which bedside nurses recognize and respond to safety concerns expressed by patients or their families.

METHODS

Twenty-five bedside nurses from 30 maternal-child, intensive, medical-surgical, and psychiatric inpatient units within an academic medical center participated in semi-structured interviews. Data were analyzed using grounded theory.

FINDINGS

Nurses reported creating space for open safety communication to foster trust and maintain patient safety and sense of security. Nurses anticipated safety concerns, invited safety discussion, were accessible, recognized insecurity, reacted in a trustworthy way, shared a plan, and followed up with patient and family.

DISCUSSION

This process involves multiple interacting components, yet was remarkably consistent across acute care settings, despite differences in nurses, patient populations, and unit cultures.

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level

BACKGROUND

To improve harm prevention, patient engagement in safety at the direct care level is advocated. For patient safety to most effectively include patients, it is critical to reflect on existing evidence, to better position future research with implications for education and practice.

METHODS

As part of a multi-phase study, which included a qualitative descriptive study (Duhn & Medves, 2018), a scoping review about patient engagement in safety was conducted. The objective was to review papers about patients' attitudes and behaviours concerning their involvement in ensuring their safe care. The databases searched included MEDLINE, CINAHL and EMBASE (year ending 2019).

RESULTS

This review included 35 papers about "Patient Attitudes" and 125 papers about "Patient Behaviours"-indicative of growing global interest in this field. Several patterns emerged from the review, including that most investigators have focused on a particular dimension of harm prevention, such as asking about provider handwashing, and there is less known about patients' opinions about their role in safety generally and how to actualize it in a way that is right for them. While patients may indicate favourable attitudes toward safety involvement generally, intention to act or actual behaviours may be quite different.

CONCLUSION

This review, given its multi-focus across the continuum of care, is the first of its kind based on existing literature. It provides an important international "mapping" of the initiatives that are underway to engage patients in different elements of safety and their viewpoints, and identifies the gaps that remain.

A Decade of Preventing Harm

Medical errors are a significant source of morbidity and mortality, and while focused efforts to prevent harm have been made, sustaining reductions across multiple categories of patient harm remains a challenge. In 2008 BJC HealthCare initiated a systemwide program to eliminate all major causes of preventable harm and mortality over a five-year period with a goal of sustaining these reductions over the subsequent five years.

METHODS

Areas of focus included pressure ulcers, adverse drug events, falls with injury, health care-associated infections, and venous thromboembolism. Initial efforts involved building system-level multidisciplinary teams, utilizing standardized project management methods, and establishing standard surveillance methods. Evidence-based interventions were deployed across the system; core standards were established while allowing for flexibility in local implementation. Improvements were tracked using actual numbers of events rather than rates to increase meaning and interpretability by patients and frontline staff.

RESULTS

Over the course of the five-year intervention period, total harm events were reduced by 51.6% (10,371 events in 2009 to 5,018 events in 2012). Continued improvement efforts over the subsequent five years led to additional harm reduction (2,605 events in 2017; a 74.9% reduction since 2009).

CONCLUSION

A combination of project management discipline, rigorous surveillance, and focused interventions, along with system-level support of local hospital improvement efforts, led to dramatic reductions in preventable harm and long-term sustainment of progress.

Lessons learned for reducing the negative impact of adverse events on patients, health professionals and healthcare organizations

Purpose

To summarize the knowledge about the aftermath of adverse events (AEs) and develop a recommendation set to reduce their negative impact in patients, health professionals and organizations in contexts where there is no previous experiences and apology laws are not present.

Data sources

Review studies published between 2000 and 2015, institutional websites and experts' opinions on patient safety.

Study selection

Studies published and websites on open disclosure, and the second and third victims' phenomenon. Four Focus Groups participating 27 healthcare professionals.

Data extraction

Study characteristic and outcome data were abstracted by two authors and reviewed by the research team.

Results of data synthesis

Fourteen publications and 16 websites were reviewed. The recommendations were structured around eight areas: (i) safety and organizational policies, (ii) patient care, (iii) proactive approach to preventing reoccurrence, (iv) supporting the clinician and healthcare team, (v) activation of resources to provide an appropriate response, (vi) informing patients and/or family members, (vii) incidents' analysis and (viii) protecting the reputation of health professionals and the organization.

Conclusion

Recommendations preventing aftermath of AEs have been identified. These have been designed for the hospital and the primary care settings; to cope with patient's emotions and for tacking the impact of AE in the second victim's colleagues. Its systematic use should help for the establishment of organizational action plans after an AE.

Complications: acknowledging, managing, and coping with human error

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

'I need complete trust in nurses' - home mechanical ventilated patients' perceptions of safety

BACKGROUND

Although home care has advanced over the last few decades, little research on patient safety has been carried out in this setting. Furthermore, it is unclear how patients perceive their situation and safety. The insiders' views might be especially relevant for technology-dependent individuals, such as users of home mechanical ventilation (HMV).

AIM

The aim of this study was to examine how HMV patients perceive their situation and what makes them feel safe or unsafe.

DESIGN

Explorative qualitative study.

METHODS

Data were collected in two regions in Germany between April and December 2014 by means of semi-structured interviews with 21 HMV patients. Thematic analysis was used to analyse data.

FINDINGS

Three themes emerged: the meaning of an interpersonal relationship between the nurse and HMV patient is expressed in the theme Being familiar - Having trust. The importance of the attentiveness of nurses for the patients' feeling of safety is described in the theme Being able to communicate - Being noticed. The theme Experiencing continuity - Feeling presence points to the organisational dimension of HMV care provision.

CONCLUSIONS

The interpersonal nurse-patient relationship plays a key role in promoting HMV patients' feeling of safety. Thus, HMV patients have a relational approach to safety. In order to enhance the patients' feeling of safety, nurses should strive to develop a trusting relationship with patients and demonstrate their presence and attentiveness. Regarding the provision of care, competent and continuous care should be made a priority.

Modeling the hospital safety partnership preferences of patients and their families: a discrete choice conjoint experiment

BACKGROUND

Patients and their families play an important role in efforts to improve health service safety.

OBJECTIVE

The objective of this study is to understand the safety partnership preferences of patients and their families.

METHOD

We used a discrete choice conjoint experiment to model the safety partnership preferences of 1,084 patients or those such as parents acting on their behalf. Participants made choices between hypothetical safety partnerships composed by experimentally varying 15 four-level partnership design attributes.

RESULTS

Participants preferred an approach to safety based on partnerships between patients and staff rather than a model delegating responsibility for safety to hospital staff. They valued the opportunity to participate in point of service safety partnerships, such as identity and medication double checks, that might afford an immediate risk reduction. Latent class analysis yielded two segments. Actively engaged participants (73.3%) comprised outpatients with higher education, who anticipated more benefits to safety partnerships, were more confident in their ability to contribute, and were more intent on participating. They were more likely to prefer a personal engagement strategy, valued scientific evidence, preferred a more active approach to safety education, and advocated disclosure of errors. The passively engaged segment (26.7%) anticipated fewer benefits, were less confident in their ability to contribute, and were less intent on participating. They were more likely to prefer an engagement strategy based on signage. They preferred that staff explain why they thought patients should help make care safer and decide whether errors were disclosed. Inpatients, those with immigrant backgrounds, and those with less education were more likely to be in this segment.

CONCLUSION

Health services need to communicate information regarding risks, ask about partnership preferences, create opportunities respecting individual differences, and ensure a positive response when patients raise safety concerns.

The right to be informed and fear of disclosure: sustainability of a full error disclosure policy at an Italian cancer centre/clinic

Background

The aim of this study was to investigate the behaviour of physicians in cases of medical error as well as the nature of the information that should be given to the patient and to ascertain whether it is possible to institute a full error disclosure policy. Data was collected through the completion of anonymous questionnaires by medical directors of the IRCCS CROB (the Oncology Centre of Basilicata, Italy).

Methods

An anonymous questionnaire consisting of 15 questions was prepared and administered to all the physicians working at the IRCCS CROB – the Oncology Centre of Basilicata. The main aim of the research was to evaluate the feasibility of adopting a full disclosure policy and the extent to which such a policy could help reduce administration and legal costs.

Results

The physicians interviewed unanimously recognize the importance of error disclosure, given that they themselves would want to be informed if they were the patients. However, 50% have never disclosed a medical error to their patients. Fear of losing the patient’s trust (33%) and fear of lawsuits (31%) are the main obstacles to error disclosure.

Conclusions

The authors found that physicians were in favour of a full policy disclosure at the IRCCS CROB – the Oncology Centre of Basilicata. Many more studies need to be carried out in order to comprehend the economic impact of a full error disclosure policy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0794-3) contains supplementary material, which is available to authorized users.

How patients can improve the accuracy of their medical records

OBJECTIVES

Assess (1) if patients can improve their medical records' accuracy if effectively engaged using a networked Personal Health Record; (2) workflow efficiency and reliability for receiving and processing patient feedback; and (3) patient feedback's impact on medical record accuracy.

BACKGROUND

Improving medical record' accuracy and associated challenges have been documented extensively. Providing patients with useful access to their records through information technology gives them new opportunities to improve their records' accuracy and completeness. A new approach supporting online contributions to their medication lists by patients of Geisinger Health Systems, an online patient-engagement advocate, revealed this can be done successfully. In late 2011, Geisinger launched an online process for patients to provide electronic feedback on their medication lists' accuracy before a doctor visit. Patient feedback was routed to a Geisinger pharmacist, who reviewed it and followed up with the patient before changing the medication list shared by the patient and the clinicians.

METHODS

The evaluation employed mixed methods and consisted of patient focus groups (users, nonusers, and partial users of the feedback form), semi structured interviews with providers and pharmacists, user observations with patients, and quantitative analysis of patient feedback data and pharmacists' medication reconciliation logs.

FINDINGS/DISCUSSION

(1) Patients were eager to provide feedback on their medications and saw numerous advantages. Thirty percent of patient feedback forms (457 of 1,500) were completed and submitted to Geisinger. Patients requested changes to the shared medication lists in 89 percent of cases (369 of 414 forms). These included frequency-or dosage changes to existing prescriptions and requests for new medications (prescriptions and over-the counter). (2) Patients provided useful and accurate online feedback. In a subsample of 107 forms, pharmacists responded positively to 68 percent of patient requests for medication list changes. (3) Processing patient feedback will requires both software algorithms and human interpretation. For the 107 forms subsample, pharmacists accepted patient input in 51 percent of cases where they could not contact the patient. Where the patient was contacted, they accepted feedback from 68 percent. This suggests there may be opportunities to automate feedback filtering and processing for more efficient (and larger scale) medication-list optimization. (4) A supportive overall e-health environment makes acceptance of an online patient feedback system more likely. Review of Geisinger usage data showed patients who completed the medication feedback form had previously accessed MyGeisinger 2.3 times as often as the average patient and initiated secure messages with a clinician 1.35 times as often as patients not involved in the pilot.

CONCLUSIONS

Patient feedback, placed in a useful workflow, can improve medical record accuracy. Electronic health record (EHR) vendors and developers need to build appropriate capabilities into applications. Continued research and development is needed for enabling health care organizations to elicit and process patient information most effectively.

Disclosure of adverse events in the United States and Canada: an update, and a proposed framework for improvement

There is consensus that physicians, health professionals and health care organizations should discuss harm that results from health care delivery (adverse events), including the reasons for harm, with patients and their families. Thought leaders and policy makers in the USA and Canada support this goal. However, there are gaps in both countries between patients and physicians in their attitudes about how errors should be handled, and between disclosure policies and their implementation in practice. This paper reviews the state of disclosure policy and practice in the two countries, and the barriers to full disclosure. Important barriers include fear of consequences, attitudes about disclosure, lack of skill and role models, and lack of peer and institutional support. The paper also describes the problem of the second victim, a corollary of disclosure whereby health care workers are also traumatized by the same events that harm patients. The presence of multiple practical and personal barriers to disclosure suggests the need for a comprehensive solution directed at multiple levels of the health care system, including health departments, institutions, local managers, professional staff, patients and families, and including legal, health system and local institutional support. At the local level, implementation could be based on a translating-evidence-into-practice framework. Applying this framework would involve the formation of teams, training, measurement and identification of local barriers to achieving universal disclosure of adverse events.

Hospital patients' reports of medical errors and undesirable events in their health care

OBJECTIVE

To investigate hospital patients' reports of undesirable events in their health care.

DESIGN

Cross-sectional mixed methods design.

PARTICIPANTS

A total of 80 medical and surgical patients (mean age 58, 56 male).

INTERVENTION

Patients were interviewed post-discharge using a survey to assess patient reports of errors or problems in their care. Patients' medical records and notes were also reviewed.

MAIN OUTCOME MEASURES

Frequency of health care process problems, medical complications and interpersonal problems, and patient willingness to report an undesirable event in their care.

RESULTS

In total, 258 undesirable events were reported (rate of 3.2 per person), including 136 interpersonal problems, 90 medical complications and 32 health care process problems. Patients identified a number of events that were reported in the medical records (30 out of 36). In addition, patients reported events that were not recorded in the medical records. Patients were more willing (P < 0.05) to report undesirable events to a researcher (as in the present case) than to a local or national reporting system.

CONCLUSION

Patients appear able to report undesirable events that occur in their health care management over and above those that are recorded in their medical records. However, patients appear more willing to report these incidents for the purpose of a study rather than to an established incident reporting system. Interventions aimed at educating and encouraging patients about incident reporting systems need to be developed in order to enhance this important contribution patients could make to improving patient safety.

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review

This systematic review identifies the factors that both support and deter patients from being willing and able to participate actively in reducing clinical errors. Specifically, we add to our understanding of the safety culture in healthcare by engaging with the call for more focus on the relational and subjective factors which enable patients' participation (Iedema, Jorm, & Lum, 2009; Ovretveit, 2009). A systematic search of six databases, ten journals and seven healthcare organisations' web sites resulted in the identification of 2714 studies of which 68 were included in the review. These studies investigated initiatives involving patients in safety or studies of patients' perspectives of being actively involved in the safety of their care. The factors explored varied considerably depending on the scope, setting and context of the study. Using thematic analysis we synthesized the data to build an explanation of why, when and how patients are likely to engage actively in helping to reduce clinical errors. The findings show that the main factors for engaging patients in their own safety can be summarised in four categories: illness; individual cognitive characteristics; the clinician-patient relationship; and organisational factors. We conclude that illness and patients' perceptions of their role and status as subordinate to that of clinicians are the most important barriers to their involvement in error reduction. In sum, patients' fear of being labelled "difficult" and a consequent desire for clinicians' approbation may cause them to assume a passive role as a means of actively protecting their personal safety.

What are Patients' Concerns about Medical Errors in an Emergency Department?

OBJECTIVES

Concerns about medical errors have recently increased. An understanding of how patients conceptualise medical error would help health care providers to allay safety concerns and increase patient satisfaction. The aim of this study was to evaluate patients' worries about medical errors and their relationship with patient characteristics and satisfaction.

METHODS

This descriptive cross-sectional study was done in the Emergency Department (ED) of a university hospital over a one week period in October 2008. A questionnaire was used to assess patients' worries about medical errors and their satisfaction levels both at an initial interview and by telephone 7 days after discharge. Data were gathered and analysed by χ2, t-tests and logistic regression.

RESULTS

Of 638 patients interviewed, 61.6% declared their satisfaction rate as good to excellent; (93 [14.6%] as poor; 152 [23.8%] as fair; 296 [46.4%] as good; 97 [15.2%] as excellent). A total of 48.3% of patients (44.5-52%, with confidence interval 95%) were concerned about the occurrence of at least one medical error. There was a clear relationship between the general satisfaction rate and having at least one concern about a medical error (Chi-square, P <0.001).

CONCLUSION

This study showed that many patients were concerned about medical errors during their emergency care. Due to the stressful situation in EDs, patients' safety and satisfaction could be improved by a better understanding of patient concerns, education of ED staff and an improvement in the patient-doctor relationship.

Patients for patient safety in China: a cross sectional study

OBJECTIVES

To investigate the baseline status of patients' awareness, knowledge, and attitudes to patient safety in China, and to determine the factors that influence patients' involvement in patient safety.

METHODS

We conducted a cross sectional survey using questionnaires adapted from recent studies on patient safety from outside China. The items included medical errors, infection, medication safety, and other aspects of patient safety. The questionnaire included 17 items and 5 domains. The survey was conducted between Jan. 2009 and Dec. 2010 involving 1000 patients from ten grade-A hospitals in seven provinces or cities in China. Most patients from the surgery departments completed the questionnaires voluntarily and anonymously. Five reviewers independently input the data into Microsoft Excel 2003, and the data were double-checked. Data were analyzed using SPSS 15.0 software for differences in the perceptions and attitudes of patients toward patient safety among different genders, ages, and regions.

RESULTS

We distributed 1000 questionnaires and collected 959 completed questionnaires (response rate: 96%). Among the respondents, 58% of patients did not know what medical error is. Sixty-five percent of patients wanted disclosure of all medical errors. After errors occurred, 58% of patients wanted explanations of all possible harms that had resulted. Among 187 patients who had experienced medical errors, 83% of patients had sought appropriate legal action. About 52% of patients understood hospital infection, but 28% patients did not know that infections could occur in hospital. Seventy-eight percent of patients thought that medical staff should wash their hands before examining patients. More than half of the patients (68%) were willing to remind the staff of hygiene if they saw unsanitary conditions in a health clinic. Only 14% of patients knew the side effects of medications that they took.

CONCLUSION

The majority of patients surveyed expressed willingness to contribute to patient safety, but their knowledge about patient safety practices was generally very limited.

Distinguishing objective from subjective assessments of the severity of medication-related safety events among people with Parkinson's disease: a qualitative study

WHAT IS KNOWN AND OBJECTIVE

Safety events indicating medication-related errors in Parkinson's disease (PD) are common but seldom studied, particularly from lay perspectives. Our objective was to study the meaning and significance to people living with PD of their experience of safety events.

METHODS

Twenty qualitative interviews were conducted by telephone with purposively sampled individuals with PD, a proxy, or both, throughout New Zealand. Themes identified from the data included joint assessments of the objective and subjective severity of the individual safety events.

RESULTS AND DISCUSSION

Most of the events indicated minor objective errors, whose severity was sometimes perceived as major, especially in the face of callous communication.

WHAT IS NEW AND CONCLUSION

Variation between objective and subjective assessments of the severity of possible errors indicated by safety events highlight the importance of distinguishing between, and using, both forms of assessment.

Disclosure of patient safety incidents: a comprehensive review

PURPOSE

Adverse events are increasingly recognized as a source of harm to patients. When such harm occurs, problems arise in communicating the situation to patients and their families. We reviewed the literature on disclosure across individual and international boundaries, including patients', healthcare professionals' and other stakeholders' perspectives in order to ascertain how the needs of all groups could be better reconciled.

DATA SOURCES

A systematic review of the literature was carried out using the search terms 'patient safety', 'medical error', 'communication', 'clinicians', 'healthcare professionals' and 'disclosure'. All articles relating to either patients' or healthcare professionals' experiences or attitudes toward disclosure were included.

RESULTS

Both patients and healthcare professionals support the disclosure of adverse events to patients and their families. Patients have specific requirements including frank and timely disclosure, an apology where appropriate and assurances about their future care. However, research suggests that there is a gap between ideal disclosure practice and reality. Although healthcare is delivered by multidisciplinary teams, much of the research that has been conducted has focused on physicians' experiences. Research indicates that other healthcare professionals also have a role to play in the disclosure process and this should be reflected in disclosure policies.

CONCLUSIONS

This comprehensive review, which takes account of the perspectives of the patient and members of the care team across multiple jurisdictions, suggests that disclosure practice can be improved by strengthening policy and supporting healthcare professionals in disclosing adverse events. Increased openness and honesty following adverse events can improve provider-patient relationships.

[Evaluation of nurses' competency in nurse-patient communication about medications: conversational analysis approach]

PURPOSE

The purpose of this study was to develop evaluation criteria for conversations about medication and to demonstrate conversational analysis with actual dialogues on medication as examples.

METHODS

This study was a secondary analysis of qualitative research using conversational analysis which showed functional phases and patterns of dialogue about medication (greeting, identifying the patient, medicating, finishing). Nurse-patient conversations were videotaped and transcribed and 75 conversations were used for analysis.

RESULTS

Not all functional phases were showed in the conversations about medication. Therefore, conversations about medication can be considered as incomplete dialogues. The evaluation-criteria were represented in terms of the structure and content of the dialogues. Structural evaluation-criteria were the same as the functional phases, as functional stage is the standard for evaluation. The criteria of evaluation for content suggested 3 domains, content, expression, and interaction with 20 items scored on a Likert-type scale of 5-points. Finally, analysis of actual conversations about medication according to the evaluative criteria were provided.

CONCLUSION

The results provide the basic data to develop educational programs and strategies to improve nurses' competency in conversation about medication.

Medication timing errors for Parkinson's disease: perspectives held by caregivers and people with Parkinson's in new zealand

Background. Common but seldom published are Parkinson's disease (PD) medication errors involving late, extra, or missed doses. These errors can reduce medication effectiveness and the quality of life of people with PD and their caregivers. Objective. To explore lay perspectives of factors contributing to medication timing errors for PD in hospital and community settings. Design and Methods. This qualitative research purposively sampled individuals with PD, or a proxy of their choice, throughout New Zealand during 2008-2009. Data collection involved 20 semistructured, personal interviews by telephone. A general inductive analysis of the data identified core insights consistent with the study objective. Results. Five themes help to account for possible timing adherence errors by people with PD, their caregivers or professionals. The themes are the abrupt withdrawal of PD medication; wrong, vague or misread instructions; devaluation of the lay role in managing PD medications; deficits in professional knowledge and in caring behavior around PD in formal health care settings; and lay forgetfulness. Conclusions. The results add to the limited published research on medication errors in PD and help to confirm anecdotal experience internationally. They indicate opportunities for professionals and lay people to work together to reduce errors in the timing of medication for PD in hospital and community settings.

Afraid in the hospital: parental concern for errors during a child's hospitalization

OBJECTIVE

(1) To determine the proportion of parents concerned about medical errors during a child's hospitalization; and (2) the association between this concern and parental self-efficacy with physician interactions.

STUDY DESIGN

Cross-sectional survey.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

Parents of children admitted to the general medical service.

OUTCOME MEASURE

Parental concern about medical errors.

METHODS

: Parents were asked their agreement with the statement "When my child is in the hospital I feel that I have to watch over the care that he/she is receiving to make sure that mistakes aren't made." We used multivariate logistic regression to examine the association between parents' self-efficacy with physician interactions and the need "to watch over a child's care," adjusting for parent and child demographics, English proficiency, past hospitalization, and social desirability bias.

RESULTS

Of 278 eligible parents, 130 completed surveys and 63% reported the need to watch over their child's care to ensure that mistakes were not made. Parents with greater self-efficacy with physician interactions were less likely to report this need (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.72-0.92). All parents who were "very uncomfortable" communicating with doctors in English reported the need to watch over their child's care to prevent mistakes.

CONCLUSIONS

Nearly two-thirds of surveyed parents felt the need to watch over their child's hospital care to prevent mistakes. Parents with greater self-efficacy with physician interactions were less likely to report the need to watch over their child's care while parents with lower English proficiency were more likely to report this need.

Disclosing medical errors to patients: a challenge for health care professionals and institutions

Medical errors occur frequently in routine health care. Historically, many of these errors were not disclosed to patients but increasingly there are calls for frank and open disclosure of errors to patients and families. This article provides an overview of what information should be disclosed about errors, what patients want to be told, the attitudes and skills of physicians in disclosure, and the barriers to effective disclosure. This article also includes a description of the changing policy environment in North America that is encouraging and mandating disclosure of errors.

Rating recommendations for consumers about patient safety: sense, common sense, or nonsense?

BACKGROUND

Although many organizations offer advice about the consumer's role in improving patient safety, little is known about these recommendations.

METHODS

The Internet and medical literature were searched to identify patient safety recommendations for consumers. Recommendations were classified by type and tabulated by frequency. Nine investigators rated each recommendation for the quality of supporting empirical evidence, magnitude of benefit, and likely patient adherence. For a consumer perspective, 22 relatives of the investigators who were also mothers rated each recommendation.

RESULTS

Twenty-six organizations identified 160 distinct recommendations; 115 (72%) addressed medication safety, 37 (23%) advised patients about preparation for hospitalization or surgery, and 18 (11%) offered general advice. Organizations most frequently advised patients to make a list of their medications (92% of organizations), to ask questions about their health and treatment (81%), to enlist an advocate (77%), and to learn about possible medication side effects (77%). Investigators assigned high scores to 11 of the 25 most frequently cited recommendations and to 4 of the 25 least common recommendations. There was little association between the frequency with which recommendations were promulgated and investigators' ratings (r = 0.27, p < .001). Investigators' scores correlated with those of the mothers (r = 0.71, p < .001).

DISCUSSION

Contrary to expectation, there was little overlap among the 160 recommendations offered by the 26 organizations. Health care organizations offer many patient safety recommendations of limited value. These organizations should offer a concise and coherent set of recommendations on the basis of evidence, magnitude of benefit, and likely adherence.

Patient error: a preliminary taxonomy

PURPOSE

Current research on errors in health care focuses almost exclusively on system and clinician error. It tends to exclude how patients may create errors that influence their health. We aimed to identify the types of errors that patients can contribute and help manage, especially in primary care.

METHODS

Eleven nominal group interviews of patients and primary health care professionals were held in Auckland, New Zealand, during late 2007. Group members reported and helped to classify types of potential error by patients. We synthesized the ideas that emerged from the nominal groups into a taxonomy of patient error.

RESULTS

Our taxonomy is a 3-level system encompassing 70 potential types of patient error. The first level classifies 8 categories of error into 2 main groups: action errors and mental errors. The action errors, which result in part or whole from patient behavior, are attendance errors, assertion errors, and adherence errors. The mental errors, which are errors in patient thought processes, comprise memory errors, mindfulness errors, misjudgments, and-more distally-knowledge deficits and attitudes not conducive to health.

CONCLUSION

The taxonomy is an early attempt to understand and recognize how patients may err and what clinicians should aim to influence so they can help patients act safely. This approach begins to balance perspectives on error but requires further research. There is a need to move beyond seeing patient, clinician, and system errors as separate categories of error. An important next step may be research that attempts to understand how patients, clinicians, and systems interact to cocreate and reduce errors.

Patients' perceptions of safety if interpersonal continuity of care were to be disrupted

OBJECTIVE

To determine if patients vary in perceptions of safety if interpersonal continuity were to be disrupted. If so, which characteristics are associated with feeling unsafe?

BACKGROUND

The extent to which patients' preference for continuity with a personal physician is due to perceptions of safety is unclear.

DESIGN

Observational study (Wisconsin Longitudinal Study Graduate and Sibling Survey).

SETTING AND PARTICIPANTS

A total of 6827 respondents (most aged 63-66 years) who completed the 2003-06 survey round.

MAIN VARIABLES STUDIED

Age, gender, marital status, education, health insurance type, illnesses, medications, length of relationship with provider and place, personality type, decision-making preference and trust in physician deliberation.

MAIN OUTCOME MEASURES

Safety perception when visiting another doctor or clinic if own doctor were not available.

RESULTS

Twelve percent of respondents felt unsafe. After adjustment, as compared to those who felt safe, those who felt unsafe were more likely to be women (Odds ratio=1.65, 95% confidence interval=1.35-2.01), have more chronic conditions (1.27, 1.08-1.50) and have a longer relationship with a usual provider: 5-9 years (1.53, 1.11-2.10) 10-14 years (1.41, 1.02-1.95) and 15 or more years (1.62, 1.20-2.17) compared to 0-4 years. Those who preferred active participation in decision making and had trust in their physician were less likely to feel safe (1.63, 1.10-2.41).

CONCLUSIONS

Certain older adults perceive being unsafe if not seeing their usual physician. Further research should investigate reasons for perceptions of safety if continuity were disrupted and any implications for care.

The perception of health care risk: patients, health care staff and society

INTRODUCTION

The Nuovo Zingarelli, dictionary of the Italian language, defines risk as "the possibility of harmful or negative consequences following not always predictable circumstances". A statistical-epidemiological type of definition is far removed from the social and psychological conception that the population attributes to the risk of harm, which is related to interior processes and emotional reactions. Information on risks interacts with knowledge, personal values and beliefs to produce a subjective expression that is perception.

MATERIALS AND METHODS

Two years after instituting the Hospital Quality and Risk Management Unit at S. Giovanni Battista Molinette Hospital (Turin, Italy) it became clear that it was necessary to determine the perception of health care risk among nursing staff. Therefore, nursing teams from eight sub-departmental units in six departments were invited to participate in an assessment project.

RESULTS

The project was undertaken by four nursing teams composed of four head nurses (project representatives) and 45 professional nurses. The aims of the project were understood by all four groups; three participated with interest, one only in part. Three groups considered that it would be useful to continue the project, while the other group did not discuss this point.

CONCLUSIONS

The project on the perception of health care risk by nursing staff revealed that mistaken identification of the patient, errors during the administration of treatment and poor communication among colleagues and with doctors and patients were the risks of error perceived as most important by nurses. Heavy work loads, staff shortages, technical and structural problems, and gaps in professional knowledge were identified as the factors related to the occurrence of adverse events. These data differed from management's perception because no incident report forms had ever been received from these nursing teams.

"Against the silence": development and first results of a patient survey to assess experiences of safety-related events in hospital

Background

Involvement of patients in the detection and prevention of safety related events and medical errors have been widely recommended. However, it has also been questioned whether patients at large are willing and able to identify safety-related events in their care. The aim of this study was to develop and pilot test a brief patient safety survey applicable to inpatient care in Swiss hospitals.

Methods

A survey instrument was developed in an iterative procedure. The instrument asks patients to report whether they have experienced specific undesirable events during their hospital stay. The preliminary version was developed together with experts and tested in focus groups with patients. The adapted survey instrument was pilot-tested in random samples of patients of two Swiss hospitals (n = 400). Responders to the survey that had reported experience of any incident were sampled for qualitative interviews (n = 18). Based on the interview, the researcher classified the reported incidents as confirmed or discarded.

Results

The survey was generally well accepted in the focus groups and interviews. In the quantitative pilot test, 125 patients returned the survey (response rate: 31%). The mean age of responders was 55 years (range 17–91, SD 18 years) and 62.5% were female. The 125 participating patients reported 94 "definitive" and 34 "uncertain" events. 14% of the patients rated any of the experienced events as "serious". The definitive and uncertain events reported with highest frequency were phlebitis, missing hand hygiene, allergic drug reaction, unavailability of documents, and infection. 23% of patients reported some or serious concerns about their safety. The qualitative interviews indicate that both, the extent of patients' uncertainty in the classification of events and the likelihood of confirmation by the interviewer vary very much by type of incident. Unexpectedly, many patients reported problems and incidents related to food and dietary intake. Overall, the in-depth interviews confirmed experiences from the focus groups that many patients feel reluctant to report undesirable events without acknowledging the presence or absence of individual responsibility or failure. Many patients reported that they did not ask or communicate about errors or near misses with staff and some patients even develop strategies to improve their safety but do not disclose these to staff.

Conclusion

Many patients experience undesirable events during hospitalization and a significant number of patients is seriously concerned about their safety. Surveying patients about experiences with safety-related events in hospital seems a valuable tool for identifying and monitoring problematic areas of care and undesirable events. Evidence from the qualitative interviews indicates that safety remains an unsaid word between patients and their care providers.

Point-of-care testing, medical error, and patient safety: a 2007 assessment

Point-of-care testing (POCT) is the fastest growing segment of a US$30 billion worldwide market. "Errors" in the testing process, as well as medical data interpretation and treatment associated with POCT, are recognized as leading to major compromises of patient safety. In today's environment, most testing errors (pre-analytical, analytical and post-analytical) can be virtually eliminated by proper design of testing systems. We cite examples of two systems that have made exceptional progress in this respect. It has been recently suggested that the basic errors associated with the testing process are amplified in the POC setting. Two of the amplifiers - incoherent regulations and failure of clinician/caregivers to respond appropriately to POCT results - lead us to recognize additional changes in today's POCT environment. The first is a willingness of manufacturers, not laboratories, to take responsibility for the quality of test results - an outgrowth of an industrial philosophy called autonomation. The second is a need to substantially modify the clinician/caregiver test utilization paradigm to take full advantage of POCT results, available on site in real time. Both have already begun to take place.

The laboratory and patient safety

Laboratory data are used extensively in patient care; consequently, laboratory errors have a tremendous impact on patient safety. Clinical laboratories were early leaders in efforts to minimize medical errors and improve patient safety. These efforts continue in many areas, including patient and specimen identification, laboratory result notification, and assistance in laboratory data interpretation. Emerging ideas on identifying and reducing laboratory errors, as well as specific strategies are reviewed and discussed with examples.

Patient-reported safety and quality of care in outpatient oncology

BACKGROUND

Although patients suffer the effects of medical errors and iatrogenic injuries, little is known about their ability to recognize these events in ambulatory specialty care.

METHODS

At a Boston cancer center in 2004, 193 adult oncology patients treated on a chemotherapy infusion unit were interviewed by four patient safety liaisons--volunteers recruited from the organization's Adult Patient and Family Advisory Council.

RESULTS

Among 193 patients, 83 reported 121 incidents. Investigators classified 2 (1%) adverse events, 4 (2%) close calls, 14 (7%) errors without risk of harm, and 101 (52%) service quality incidents. Respondents reported high staff compliance with safe practices such as identity checking (95%). Examining the most serious described by each of 42 (22%) respondents who reported a recent unsafe experience, investigators classified only one adverse event, 3 close calls, 9 harmless errors, and 27 service quality incidents.

DISCUSSION

Patients' perception of unsafe care was surprising, given the same patients' recognition of consistent application of safe practices, such as the use of two forms of identification before performing tests and administering treatments. Many ambulatory oncology patients also reported poor service quality. The relationship between patient perception of safe care, medical injury, and service quality merits further study.