Sensemaking and the co-production of safety: a qualitative study of primary medical care patients

Why did this happen to me? Causal attributions of illness and cultural health capital

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

Safer Patients Empowered to Engage and Communicate about Health (SPEECH) in primary care: a feasibility study and process evaluation of an intervention for older people with multiple long-term conditions (multimorbidity)

BACKGROUND

Older people with multiple long-term conditions (multimorbidity) (MLTC-M) experience difficulties accessing and interacting with health and care services. Breakdowns in communication between patients and staff can threaten patient safety. To improve communication and reduce risks to patient safety in primary care, we developed an intervention: Safer Patients Empowered to Engage and Communicate about Health (SPEECH). SPEECH comprises a booklet for patients and an associated guide for staff. The booklet is designed to provide patients with information about staff and services, skills to prepare and explain, and confidence to speak up and ask.

METHODS

A single-arm mixed methods feasibility study with embedded process evaluation. General practices in the North West of England were recruited. Participating practices invited patients aged 65+ with MLTC-M who had an appointment scheduled during the study period. Patients were asked to complete questionnaires at baseline and follow-up (four to eight weeks after being sent the patient booklet), including the Consultation and Relational Empathy measure, Empowerment Scale, Multimorbidity Treatment Burden Questionnaire, and Primary Care Patient Measure of Safety. Staff completed questionnaires at the end of the study period. A sub-sample of patients and staff were interviewed about the study processes and intervention. Patients and the public were involved in all aspects of the study, from generation of the initial idea to interpretation of findings.

RESULTS

Our target of four general practices were recruited within 50 days of the study information being sent out. A fifth practice was recruited later to boost patient recruitment. We received expressions of interest from 55 patients (approx. 12% of those invited). Our target of 40 patient participants completed baseline questionnaires and were sent the SPEECH booklet. Of these, 38 (95%) completed follow-up. Patients found the intervention and study processes acceptable, and staff found the intervention acceptable and feasible to deliver.

CONCLUSIONS

Our findings suggest the intervention is acceptable, and it would be feasible to deliver a trial to assess effectiveness. Prior to further evaluation, study processes and the intervention will be updated to incorporate suggestions from participants.

TRIAL REGISTRATION

The study was registered on the ISRCTN registry (ISRCTN13196605: https://doi.org/10.1186/ISRCTN13196605 ).

The patient experience of skill mix changes in primary care: an in-depth study of patient 'work' when accessing primary care

BACKGROUND

This paper presents insights into patient experiences of changes in workforce composition due to increasing deployment in general practice of practitioners from a number of different professional disciplines (skill mix). We explore these experiences via the concept of 'patient illness work'; how a patient's capacity for action is linked to the work arising from healthcare.

METHODS

We conducted four focus group interviews with Patient Participation Group members across participating English general practitioner practices. Thematic analysis and a theoretical lens of illness work were used to explore patients' attempts to understand and navigate new structures, roles and ways to access healthcare.

RESULTS

Participants' lack of knowledge about incoming practitioners constrained their agency in accessing primary care. They reported both increased and burdensome illness work as they were given responsibility for navigating and understanding new systems of access while simultaneously understanding new practitioner roles.

CONCLUSIONS

While skill mix changes were not resisted by patients, they were keen to improve their agency in capacity to access, by being better informed about newer practitioners to accept and trust them. Some patients require support to navigate change, especially where new systems demand specific capacities such as technological skills and adaptation to unfamiliar practitioners.

A narrative journey into the borderland of patient safety: Toward an expanded, relational concept of safety

"Patient safety" is routinely defined in health services globally as "safety for patients against harm and risk of injury in health care." (Danish Board of Quality in Health Care, 2022, p. 28; translated by the author). This is a standardized, broad, and general definition of what counts as safety. In this article, I argue for an expanded, relational concept of patient safety revolving around experienced patient safety. Recognizing safety as vital for all groups of patients, I follow a dialogical, critical-reflexive approach to focus on safety in a somatic hospital setting in Denmark as it is experienced by people with lived experience of mental distress. Safety in this context is often compromised, contributing to inequity in health for people with mental distress. I present and analyze the narratives of two experts by experience about their somatic hospital stay. As an analytical approach, I draw on Frank's dialogical narrative analysis together with elements from Bakhtin's theory of dialogue and Foucault's theory of power/knowledge. Forefronting voices of those rarely asked and seldom heard, dialogical narrative analysis provides insight into how "patient safety" is enacted through situated negotiations of meaning in the narratives of people with lived experience. The storytellers are continuously struggling to fit in and to be seen as human beings, trying to resist public narratives on mental distress that threaten to limit their scope of action and who they can become. The discussion highlights how unintended emotional and psychosocial harm limit the benefits of patient safety for certain groups in society. In particular, shame, individualized responsibility, and internalized inferiority hinder equity in health. Building on my analysis, I suggest a collaborative, participatory approach for coproducing further knowledge through joint analysis with people with lived experience and nurses from somatic hospital wards.

Patients' Perceptions of Safety in Primary Healthcare Settings: A Cross-Sectional Study in the Qassim Region of Saudi Arabia

This study assessed patients' perceptions of safety and experiences in primary healthcare in the Qassim region of Saudi Arabia. Between July and September 2022, 730 patients from primary healthcare centers were surveyed using a multi-staged cluster random sampling approach. The Patient-Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was used to measure patients' perceived safety and experience in primary healthcare settings within the past year. Descriptive analyses were performed to report patients' perceived safety experiences. The statistical analysis examined individual items and scales. A considerable proportion of patients reported encountering safety problems, ranging from 11% (vaccine-related) to 27% (diagnosis-related). Diagnostic errors were the most common perceived safety problem (26.7%), followed by communication issues (24.1%) and medication errors (16.3%). Between 26% and 40% experienced harm, including financial problems (40%), increased care needs (32.4%), physical health issues (32%), limitations in activities (30.6%), increased healthcare needs (30.2%), and mental health concerns (26.8%). Patient-reported safety experiences reported in our study offer valuable insights into primary care safety in Saudi Arabia. Collecting routine patient feedback is crucial for addressing identified safety problems and implementing standardized procedures.

"You just want to feel safe when you go to a healthcare professional:" Intimate partner violence and patient safety

Since the early 1990s, researchers and policymakers in the United States have addressed the concept of patient safety in healthcare systems. Traditionally, scholars have conceptualized patient safety as health care that is free from medical error and harm. However, sociologists have called for a more complex understanding of patient safety that includes relational aspects of safety. Although marginalized groups face unique threats to safety, intimate partner violence (IPV) survivors have been largely overlooked within the literature on patient safety. This study addresses that gap. Using the case of IPV, I find that survivors construct healthcare spaces as ideologically safe, but their experiences do not reflect this. Survivors' narratives reveal that patient safety is complex, multi-faceted, and relational. I argue that experiences of safety, or lack thereof, are situated within larger systems of organizational power, relational power hierarchies, and systems of inequalities. These findings have implications when considering how to improve IPV survivors' safety in healthcare settings.

Sensemaking in the early stages of the COVID-19 pandemic: A narrative exploration of polarised morality in an NHS Trust

This article presents an analysis of personal diaries kept by health-care staff within a specialist NHS Trust in England during the initial 3 months of the COVID-19 pandemic. It adopts a moral sensemaking perspective to explore how NHS employees mobilised and reframed ideas of right and wrong in order to make sense of unprecedented uncertainty and displacement. By focussing on how the macro and micro politics of the pandemic were played out in the organisation, the study finds that polarised moral judgements were invoked in order to justify and rationalise a broad array of associated emergent emotions, intuitions, behaviours and practices. This polarisation of moral responses could be seen as a desire to bring order out of chaos and put matters back into place following displacement. This is inevitably an ongoing, complex and variegated enterprise whose results can be as often discomforting as they can be reassuring. Indeed, while moral sensemaking was partly beneficial for staff in that it promoted a greater sense of camaraderie and support for others, it also appeared to have darker consequences in terms of staff wellbeing and the development of more impermeable social boundaries across the organisation through processes of moral 'othering'.

Development of 2 Short Patient-Report Questionnaires of Patient Safety in Primary Care

OBJECTIVES

The Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) is a valid and reliable instrument (61 items across 5 domains) of patients' perceptions of safety. Stakeholder feedback has supported shorter versions for improving choice and facilitating uptake of routine patient-centered evaluation. We sought to develop 2 shorter versions of PREOS-PC: one including the shortest possible scales that met established measurement performance standards and a screening version including a single item per domain.

METHODS

A total of 1244 patients from 45 general practices across England completed PREOS-PC questionnaires. All scale items in PREOS-PC underwent Item Response Theory analysis, applying standard criteria for the item reduction. Cognitive debriefing from 10 patient interviews allowed for the assessment of the instruments' readability. The instruments' psychometrics properties were reassessed in a validation sample of 1557 patients in 21 English general practices.

RESULTS

"PREOS-PC Compact" includes 25 items and 2 open-ended questions across the 5 domains, 44% of the length of the original instrument. "PREOS-PC Screen" consists of 6 items: the best-performing single items for 2 domains, 1 item modified from original items for each of the remaining 3 domains, and 1 open-ended question. The evaluation of the instruments confirmed they were acceptable to patients and met standards for readability; construct, convergent, and divergent validity; and reliability.

CONCLUSIONS

PREOS-PC Compact meets high-performance standards while reducing patient burden for routine monitoring of patient safety in primary care. PREOS-PC Screen is a concise tool apt for incorporation into audits and to target more in-depth review as needed.

Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study

Background

The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care.

Aim

To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness.

Design and setting

An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness.

Method

Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach.

Results

The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment.

Conclusion

The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote ‘by default’ and instead take into consideration both the clinical and social factors underpinning health.

How do consumers respond when presented with novel doctor performance information? A multivariate regression analysis

Background

There is an array of attributes one may consider when selecting a doctor. Consumers must generally select providers in the absence of any standardized performance information about these attributes at the doctor level. Some attributes may be less salient to consumers until presented with novel performance data. Innate decision‐making regret, style and skill may be important, given the complexity of processing and trading off on numerous attributes.

Objective

There has been limited opportunity to study consumer behaviour in the presence of doctor‐level quality information, as these data are not widely available. This study explores how consumers interact with doctor‐level performance data, considering their decision‐making regret, style and skill. Specifically, it examines how consumers rate 10 doctor attributes before and after exposure to doctor‐level quality information.

Methods

The study utilizes data from the SelectMD 2.0 Provider Choice Experiment. Respondents (n = 1247) were presented with a mock website reporting quality information and asked to choose a doctor. Difference scores are calculated based on participants' ratings of 10 attributes before and after the experiment and a multivariate ordered probit regression is considered to study the association between the predictors and 10 response outcomes.

Results

Consumers change their valuation of doctor attributes following exposure to quality data. As expected, consumers upgrade their valuation of the safety and technical quality attributes, but this is specifically associated with a greater tendency to regret decisions. Instead, those with a more dependent decision‐making style downgrade reputation, while those with better decision‐making skill downgrade the bedside manner and safety attributes.

Patient or Public Contribution

Consumers/patients participated in the pilot testing of the website used for the experiment.

Nature and type of patient-reported safety incidents in primary care: cross-sectional survey of patients from Australia and England

BACKGROUND

Patient engagement in safety has shown positive effects in preventing or reducing adverse events and potential safety risks. Capturing and utilising patient-reported safety incident data can be used for service learning and improvement.

OBJECTIVE

The aim of this study was to characterise the nature of patient-reported safety incidents in primary care.

DESIGN

Secondary analysis of two cross sectional studies.

PARTICIPANTS

Adult patients from Australian and English primary care settings.

MEASURES

Patients' self-reported experiences of safety incidents were captured using the validated Primary Care Patient Measure of Safety questionnaire. Qualitative responses to survey items were analysed and categorised using the Primary Care Patient Safety Classification System. The frequency and type of safety incidents, contributory factors, and patient and system level outcomes are presented.

RESULTS

A total of 1329 patients (n=490, England; n=839, Australia) completed the questionnaire. Overall, 5.3% (n=69) of patients reported a safety incident over the preceding 12 months. The most common incident types were administration incidents (n=27, 31%) (mainly delays in accessing a physician) and incidents involving diagnosis and assessment (n=16, 18.4%). Organisation of care accounted for 27.6% (n=29) of the contributory factors identified in the safety incidents. Staff factors (n=13, 12.4%) was the second most commonly reported contributory factor. Where an outcome could be determined, patient inconvenience (n=24, 28.6%) and clinical harm (n=21, 25%) (psychological distress and unpleasant experience) were the most frequent.

CONCLUSIONS

The nature and outcomes of patient-reported incidents differ markedly from those identified in studies of staff-reported incidents. The findings from this study emphasise the importance of capturing patient-reported safety incidents in the primary care setting. The patient perspective can complement existing sources of safety intelligence with the potential for service improvement.

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 Patient Safety Toolkit for Family Practices

OBJECTIVE

Major gaps remain in our understanding of primary care patient safety. We describe a toolkit for measuring patient safety in family practices.

METHODS

Six tools were used in 46 practices. These tools were as follows: National Health Service Education for Scotland Trigger Tool, National Health Service Education for Scotland Medicines Reconciliation Tool, Primary Care Safequest, Prescribing Safety Indicators, Patient Reported Experiences and Outcomes of Safety in Primary Care, and Concise Safe Systems Checklist.

RESULTS

Primary Care Safequest showed that most practices had a well-developed safety climate. However, the trigger tool revealed that a quarter of events identified were associated with moderate or substantial harm, with a third originating in primary care and avoidable. Although medicines reconciliation was undertaken within 2 days in more than 70% of cases, necessary discussions with a patient/carer did not always occur. The prescribing safety indicators identified 1435 instances of potentially hazardous prescribing or lack of recommended monitoring (from 92,649 patients). The Concise Safe Systems Checklist found that 25% of staff thought that their practice provided inadequate follow-up for vulnerable patients discharged from hospital and inadequate monitoring of noncollection of prescriptions. Most patients had a positive perception of the safety of their practice although 45% identified at least one safety problem in the past year.

CONCLUSIONS

Patient safety is complex and multidimensional. The Patient Safety Toolkit is easy to use and hosted on a single platform with a collection of tools generating practical and actionable information. It enables family practices to identify safety deficits that they can review and change procedures to improve their patient safety across a key sets of patient safety issues.

Protocol for a non-randomised feasibility study evaluating a codesigned patient safety guide in primary care

INTRODUCTION

Patients and carers should be active partners in patient safety with healthcare professionals and be empowered to use personalised approaches to identify safety concerns and work together to prevent them. This protocol paper details a study to examine the feasibility of a multicomponent intervention to involve patients and/or carers in patient safety in primary care in the UK.

METHODS AND ANALYSIS

This is a two-phase, non-randomised feasibility mixed methods pragmatic study of a patient safety guide for primary care (PSG-PC). 8 general practices will recruit 120 patient and/or carer participants. All patient and/or carer participants will receive the PSG-PC. It will examine the feasibility and acceptability of the PSG-PC in primary care settings in patients aged 18 years or older who attend appointments at general practice with health professionals four or more times per year as either patients or carers. It will identify secondary outcomes for improving patient safety, health status and patient empowerment, and reducing health service utilisation over 6 months between baseline and 6-month follow-ups. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients and practices will be needed. The study will be undertaken between January 2020 and September 2021.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the National Health Service London-West London and Gene Therapy Advisory Committee Research Ethics Committee (reference: 19/LO/1289). Research findings will be disseminated with participating general practices and shared in a range of different ways to engage different audiences, including presenting at international and national conferences, publishing in open-access, peer-reviewed journals and facilitating dissemination workshops within local communities with patients, carers and healthcare professionals.

TRIAL REGISTRATION NUMBER

ISRCTN90222092.

Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach

Background

Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes.

Methods

An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored.

Discussion

It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

Identifying Factors Leading to Harm in English General Practices: A Mixed-Methods Study Based on Patient Experiences Integrating Structural Equation Modeling and Qualitative Content Analysis

OBJECTIVE

The aim of the study was to identify the main factors leading to harm in primary care based on the experiences reported by patients.

METHODS

We conducted a mixed-methods, cross-sectional study in 45 primary care centers in England. A random sample of 6736 patients was invited to complete the Patient-Reported Experiences and Outcomes of Safety in Primary Care questionnaire. We fitted structural equation modeling on the quantitative data (n = 1244 respondents) to identify contributory factors and primary incidents leading to harm. We conducted content analyses of responses to seven open-ended questions (n = 386) to obtain deeper insight into patient perceptions of the causes of harm experienced. Results from quantitative and qualitative analyses were triangulated.

RESULTS

Patients reported harm related to physical health (13%), pain (11%), and mental health (19%) and harm that increased limitations in social activities (14%). Physical harm was associated with incidents affecting diagnosis (β = 0.43; delayed and wrong), and treatment (0.12; delayed, wrong treatment, or dose), which were in turn associated with incidents with patient-provider communication, coordination between providers, appointments, and laboratory tests. Pain was associated with laboratory tests (0.21; caused when collecting blood or tissue samples) and with problems booking an appointment when needed (0.13; delaying treatment for pain). Harm to mental health was associated with incidents related to the following: diagnosis (0.28), patient-provider communication (0.18), appointments (0.17), coordination between different providers (0.14), and laboratory tests (0.12). Harm increasing limitations in social activities was associated with incidents related to diagnosis (0.42) and diagnostic and monitoring procedures (0.20).

CONCLUSIONS

Our findings suggest the need for patient-centered strategies to reduce harm in primary care focusing on the improvement of the quality of diagnosis and patient-provider communication.

Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers

Background

Multiple changes are made to older patients’ medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post‐discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life.

Aim

To explore the experiences of older patients and their family carers as they enacted post‐discharge medicines management.

Design

Semi‐structured interviews took place in participants’ homes, approximately two weeks after hospital discharge. Data analysis used the Framework method.

Setting and participants

Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty‐seven participants aged 75 plus who lived with long‐term conditions and polypharmacy, and nine family carers, were interviewed.

Findings

Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health‐care professionals about medicines changes often lacked detail, which disrupted some participants’ knowledge and medicines management capabilities. Participants used multiple strategies to support post‐discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied.

Discussion and conclusion

Participants experienced gaps in their post‐discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines‐related care during the hospital‐to‐home transition.

The personalised discharge letter: the experience of patients and parents from the Filadelfia Epilepsy Hospital

OBJECTIVE

To examine the experience of a discharge letter received by patients suffering from epilepsy and parents with children who suffer from epilepsy.

DESIGN

Qualitative research inspired by a phenomenological methodology approach.

SETTING

Face-to-face interviews with patients and parents of epileptic children in their own homes.

SAMPLE

Participants (total n = 11).

METHODS

In-depth interviews were recorded verbatim, transcribed and analysed.

RESULTS

Two themes were identified: (i) it was written about me and (ii) a sense of feeling secure. By being discharged with a personalised letter, the participants felt seen and heard. The discharge letter enabled them to contact their doctor and the Filadelfia hospital more efficiently if needed. Parents indicated that the discharge letter bridged the uncertainty that they often experienced when dealing with the child's school or authorities in general.

CONCLUSIONS

The discharge letter enables the participants to make the transition into everyday life with the best and most up-to-date information about themselves and their current condition as an epilepsy patient. The discharge letter empowers the patient or parents to face everyday life. The discharge becomes a kind of passport to the outside world when encountering the general practitioner, the school or other circumstances where the patient engages. The discharge letter becomes a patient-centred tool proving that enhanced communication and understanding between healthcare professionals, patients and parents succeeds. This example could be transferable to other hospitals to heighten the patient's self-efficacy and quality of life after being discharged from the hospital.

Patient safety in marginalised groups: a narrative scoping review

Background

Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising.

Methods

Scoping review. Systematic searches were performed across six electronic databases in September 2019. The time frame for searches of the respective databases was from the year 2000 until present day.

Results

The searches yielded 3346 articles, and 67 articles were included. Patient safety issues were identified for fourteen different marginalised patient groups across all studies, with 69% (n = 46) of the studies focused on four patient groups: ethnic minority groups, frail elderly populations, care home residents and low socio-economic status. Twelve separate patient safety issues were classified. Just over half of the studies focused on three issues represented in the patient safety literature, and in order of frequency were: medication safety, adverse outcomes and near misses. In total, 157 individual contributing or associated factors were identified and mapped to one of seven different factor types from the Framework of Contributory Factors Influencing Clinical Practice within the London Protocol. Patient safety issues were mostly multifactorial in origin including patient factors, health provider factors and health care system factors.

Conclusions

This review highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments. Such understanding provides a basis for working collaboratively to co-design training, services and/or interventions designed to remove or at the very least minimise these increased risks.

Trial registration

Not applicable for a scoping review.

Patients' Experiences of Participating Actively in Shared Decision-Making in Mental Care

BACKGROUND

Patients in mental care express a wish for more active participation. Shared decision-making is a way of increasing patient participation. There is lack of research into what the shared decision-making process means and how the patients can participate in and experience it in the context of mental care.

OBJECTIVE

To describe patient participation in shared decision-making in the context of indoor mental care.

METHOD

A qualitative content analysis of data from in-depth interviews with 16 patients was performed.

RESULTS

One main theme was revealed: thriving in relation to participating actively in a complementary ensemble of care, which represented the red thread between 2 themes: having mental space to discover my way forward and being in a position to express my case.

CONCLUSION

Patients can participate actively in shared decision-making when the patients' and the mental health-care professionals' joint expertise is applied throughout their mental care. The patients experience thriving when participating actively in a complementary ensemble of care.

Rural general practice patients' coping with hazards and harm: an interview study

OBJECTIVE

The aim of this study is to identify and analyse rural general practice patients' experiences of hazards and harm that comprise adverse events, and their strategies for coping with them.

DESIGN

Interview study using systematic text condensation and coping strategy theory in an abductive analysis process.

SETTING

Nine rural general practice clinics in Norway.

PARTICIPANTS

Twenty participants, aged 21-79 years, all presenting with recent onset of somatic and/or psychiatric complaints.

RESULTS

Participating rural general practice patients described their experiences of a variety of hazards and harms. Their three most discussed cognitive and behavioural coping strategies were: (1) to accept the events; (2) to confront them and (3) to engage in planful problem-solving. While the participants demonstrated a tendency toward accepting hazards and harm that their regular general practitioner created, they were often willing to confront those that locum (ie, substitute) general practitioners created. Participants used planful problem-solving in situations they deemed hazardous, such as breaches of confidentiality or not being taken seriously, as well as during potential/actual emergencies.

CONCLUSIONS

Patients at rural general practice clinics actively identify and respond to hazards and harm, applying three coping strategies. Thus, patients themselves may serve as an important safety barrier against hazards and harm; their potential contributions to improving patient safety must be appreciated accordingly and reflected in future research as well as in everyday clinical practice.

Patients' Conceptualizations of Responsibility for Healthcare: A Typology for Understanding Differing Attributions in the Context of Patient Safety

This study examines how patients conceptualize "responsibility" for their healthcare and make sense of the complex boundaries between patient and professional roles. Focusing on the specific case of patient safety, narrative methods were used to analyze semistructured interviews with 28 people recently discharged from hospital in England. We present a typology of attribution, which demonstrates that patients' attributions of responsibility to staff and/or to patients are informed by two dimensions of responsibility: basis and contingency. The basis of responsibility is the reason for holding an individual or group responsible. The contingency of responsibility is the extent to which that attribution is contextually situated. The article contributes to knowledge about responsibility in complex organizational environments and offers a set of conceptual tools for exploring patients' understanding of responsibility in such contexts. There are implications for addressing patient engagement in care, within and beyond the field of patient safety.

Navigating and making sense of urgent and emergency care processes and provision

Background

Whilst many health systems offer a range of urgent and emergency care services to deal with the need for unscheduled care, these can be problematic to navigate.

Objective

To explore how lay people make sense of urgent care provision and processes.

Design

Qualitative study, incorporating citizen panels and longitudinal semi‐structured qualitative interviews.

Setting and Participants

Two citizens’ panels, comprising purposively selected public populations—a group of regular users and a group of potentially marginalized users of urgent and emergency care. Semi‐structured interviews were conducted with 100 people, purposively sampled to include those over 75, aged 18‐26 years, and from East/Central Europe. A sub‐sample of 41 people received a second interview at +6‐12 months. Framework analysis was thematic and comparative, moving through coding to narrative and interpretive summaries.

Findings and Discussion

Participants narratives illuminated considerable uncertainty and confusion regarding urgent and emergency care provision which in part could be traced to the contingent nature of urgent and emergency care need. Accounts of emergency care provision were underpinned by strong moral positioning of appropriate help‐seeking, demarcating legitimate service use that echoed policy rhetoric, but did not necessarily translate into individual behaviour. People struggled to make sense of urgent care provision making navigating “appropriate” use problematic.

Conclusions

The focus on help‐seeking behaviour, rather than sense‐making, makes it difficult to move beyond the polarization of “appropriate” and “inappropriate” service use. A deeper analysis of sense‐making might shift the focus of attention and allow us to intervene to reshape understandings before this point.

Safety work and risk management as burdens of treatment in primary care: insights from a focused ethnographic study of patients with multimorbidity

Background

In primary health care, patient safety failures can arise in service access, doctor-patient relationships, communication between care providers, relational and management continuity, or technical procedures. Through the lens of multimorbidty, and using qualitative ethnographic methods, our study aimed to illuminate safety issues in primary care.

Methods

Data were triangulated from electronic health records (EHRs); observation of primary care consultations; annual interviews with patients, (informal) care providers and GPs. A thematic analysis of observation, interview and field note material sought to describe the patient safety issues encountered and any associated factors or processes. A more detailed longitudinal description of 6 cases was used to contextualise safety issues identified in observation, interviews and EHRs.

Results

Twenty-six patients were recruited. Events which could lead to harm were found in all areas of a framework based on published literature. “Under” and “over” consultation as a precursor of safety failures emerged through thematic analysis of observation and interview material. Other findings concerned workload (for doctors and patients) and the limitations of short consultation times. There were differences in health data collected directly from the patients versus that found in EHRs. Examples included reference to a stroke history and diagnoses for CKD and hypertension. Case study analysis revealed specific issues which appeared contextual to safety concerns, mostly around the management of polypharmacy and patient medication adherence. Clinical imperatives appear around risk management, but the study findings point to a potential conflict with patient expectations around investigation, diagnosis and treatment.

Discussion

Patient safety work involves further burdens on top of existing workload for both clinicians and patients. In this conceptualisation, safety work seemingly forms part of a negative feedback loop with patient safety itself. A line of argument drawn from the triangulation of findings from different sources, points to a tension between the desirability of a minimally disruptive medicine versus safety risks possibly associated with ‘under’ or ‘over’ consultation. Multimorbidity acts as a magnifier of tensions in the delivery of health services and quality care in general practice. More attention should be put on system design than patient or professional behaviour.

Mindful organizing in patients' contributions to primary care medication safety

Background

There is a need to ensure that the risks associated with medication usage in primary health care are controlled. To maintain an understanding of the risks, health‐care organizations may engage in a process known as “mindful organizing.” While this is typically conceived of as involving organizational members, it may in the health‐care context also include patients. Our study aimed to examine ways in which patients might contribute to mindful organizing with respect to primary care medication safety.

Method

Qualitative focus groups and interviews were carried out with 126 members of the public in North West England and the East Midlands. Participants were taking medicines for a long‐term health condition, were taking several medicines, had previously encountered problems with their medication or were caring for another person in any of these categories. Participants described their experiences of dealing with medication‐related concerns. The transcripts were analysed using a thematic method.

Results

We identified 4 themes to explain patient behaviour associated with mindful organizing: knowledge about clinical or system issues; artefacts that facilitate control of medication risks; communication with health‐care professionals; and the relationship between patients and the health‐care system (in particular, mutual trust).

Conclusions

Mindful organizing is potentially useful for framing patient involvement in safety, although there are some conceptual and practical issues to be addressed before it can be fully exploited in this setting. We have identified factors that influence (and are strengthened by) patients’ engagement in mindful organizing, and as such would be a useful focus of efforts to support patient involvement.

Identifying primary care patient safety research priorities in the UK: a James Lind Alliance Priority Setting Partnership

OBJECTIVES

To identify the top 10 unanswered research questions for primary care patient safety research.

DESIGN

A modified nominal group technique.

SETTING

UK.

PARTICIPANTS

Anyone with experience of primary care including: patients, carers and healthcare professionals. 341 patients and 86 healthcare professionals submitted questions.

MAIN OUTCOMES

A top 10, and top 30, future research questions for primary care patient safety.

RESULTS

443 research questions were submitted by 341 patients and 86 healthcare professionals, through a national survey. After checking for relevance and rephrasing, a total of 173 questions were collated into themes. The themes were largely focused on communication, team and system working, interfaces across primary and secondary care, medication, self-management support and technology. The questions were then prioritised through a national survey, the top 30 questions were taken forward to the final prioritisation workshop. The top 10 research questions focused on the most vulnerable in society, holistic whole-person care, safer communication and coordination between care providers, work intensity, continuity of care, suicide risk, complex care at home and confidentiality.

CONCLUSIONS

This study was the first national prioritisation exercise to identify patient and healthcare professional priorities for primary care patient safety research. The research priorities identified a range of important gaps in the existing evidence to inform everyday practice to address primary care patient safety.

Empowering people to help speak up about safety in primary care: Using codesign to involve patients and professionals in developing new interventions for patients with multimorbidity

Background

Multimorbidity, defined as the presence of two or more long‐term conditions, is increasingly common in primary care, and patients with multimorbidity may face particular barriers to quality of care and increased safety risks due to the complexity of managing multiple conditions. Consistent with calls to directly involve service users in improving care, we aimed to use design materials to codesign new interventions to improve safety in primary care.

Design

We drew on two established methods—accelerated experience‐based codesign and the future workshop approach. We synthesized design materials based on research into the patient experience of safety and multimorbidity in primary care to enable both patients, service users and carers, and primary health‐care professionals to propose interventions to improve care.

Results

Both patients and professionals prioritized polypharmacy as a threat to safety. Their recommendations for supportive interventions were consistent with Burden of Treatment theory, emphasizing the limited capacity of patients with multimorbidity and the need for services to proactively offer support to reduce the burden of managing complex treatment regimes.

Discussion & Conclusions

The process was feasible and acceptable to participants, who valued the opportunity to jointly propose new interventions. The iterative workshop approach enabled the research team to better explore and refine the suggestions of attendees. Final recommendations included the need for accessible reminders to support medication adherence and medication reviews for particularly vulnerable patients conducted with pharmacists within GP practices.

Threats to patient safety in primary care reported by older people with multimorbidity: baseline findings from a longitudinal qualitative study and implications for intervention

Background

In primary care, older patients with multimorbidity (two or more long-term conditions) are especially likely to experience patient safety incidents. Risks to safety in this setting arise as a result of patient, staff and system factors; particularly where these interact or fail to do so.

Recent research and policy highlight the important contribution patients can make to improving safety. Older patients with multimorbidity may have the most to gain from increasing their involvement but before interventions can be developed to support them to improve their patient safety, more needs to be known about how this is threatened and how patients respond to perceived threats.

We sought to identify and describe threats to patient safety in primary care among older people with multimorbidity, to provide a better understanding of how these are experienced and to inform the development of interventions to reduce risks to patient safety.

Methods

Twenty-six older people, aged 65 or over, with multimorbidity were recruited to a longitudinal qualitative study. At baseline, data on their health and healthcare were collected through semi-structured interviews. Data were analysed thematically, using a framework developed from a previous synthesis of qualitative studies of patient safety in primary care.

Results

Threats to patient safety were organised into six themes, across three domains of health and care. These encompassed all aspects of the patient journey, from access to everyday management. Across the journey, many issues arose due to poor communication, and uncoordinated care created extra burdens for patients and healthcare staff. Patients’ sense of safety and trust in their care providers were especially threatened when they felt their needs were ignored, or when they perceived responses from staff as inappropriate or insensitive.

Conclusions

For older patients with multimorbidity, patient safety is intrinsically linked to the challenges people face when managing health conditions, navigating the healthcare system, and negotiating care. We consider the implications of this for the development of interventions to reduce threats to patient safety. Potential patient-centred mechanisms include providing patients with more realistic expectations for primary care, and supporting them to communicate their needs and concerns more effectively.

Electronic supplementary material

The online version of this article (doi: 10.1186/s12913-017-2727-9) contains supplementary material, which is available to authorized users.

Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire

BACKGROUND

There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives.

OBJECTIVE

To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety.

METHODS

The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care.

RESULTS

A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment.

CONCLUSION

This study identified a number of patient-centred recommendations for improving patient safety in English general practices.

Parents' Perspectives on Navigating the Work of Speaking Up in the NICU

OBJECTIVE

To describe parents' perspectives and likelihood of speaking up about safety concerns in the NICU and identify barriers and facilitators to parents speaking up.

DESIGN

Exploratory, qualitatively driven, mixed-methods design.

SETTING

A 50-bed U.S. academic medical center, open-bay NICU.

PARTICIPANTS

Forty-six parents completed questionnaires, 14 of whom were also interviewed.

METHODS

Questionnaires, interviews, and observations with parents of newborns in the NICU were used. The qualitative investigation was based on constructivist grounded theory. Quantitative measures included ratings and free-text responses about the likelihood of speaking up in response to a hypothetical scenario about lack of clinician hand hygiene. Qualitative and quantitative analyses were integrated in the final interpretation.

RESULTS

Most parents (75%) rated themselves likely or very likely to speak up in response to lack of hand hygiene; 25% of parents rated themselves unlikely to speak up in the same situation. Parents engaged in a complex process of Navigating the work of speaking up in the NICU that entailed learning the NICU, being deliberate about decisions to speak up, and at times choosing silence as a safety strategy. Decisions about how and when to speak up were influenced by multiple factors including knowing my baby, knowing the team, having a defined pathway to voice concerns, clinician approachability, clinician availability and friendliness, and clinician responsiveness.

CONCLUSION

To engage parents as full partners in safety, clinicians need to recognize the complex social and personal dimensions of the NICU experience that influence parents' willingness to speak up about their safety concerns.

Patients' evaluations of patient safety in English general practices: a cross-sectional study

BACKGROUND

Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients.

AIM

To examine patient-reported experiences and outcomes of patient safety in primary care.

DESIGN AND SETTING

Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England.

METHOD

A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice).

RESULTS

Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]).

CONCLUSION

Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation.

Patient-reported safety incidents in older patients with long-term conditions: a large cross-sectional study

BACKGROUND

Increasing evidence suggests that patient safety is a serious concern for older patients with long-term conditions. Despite this, there is a lack of research on safety incidents encountered by this patient group. In this study, we sought to examine patient reports of safety incidents and factors associated with reports of safety incidents in older patients with long-term conditions.

METHODS

The baseline cross-sectional data from a longitudinal cohort study were analysed. Older patients (n=3378 aged 65 years and over) with a long-term condition registered in general practices were included in the study. The main outcome was patient-reported safety incidents including availability and appropriateness of medical tests and prescription of wrong types or doses of medication. Binary univariate and multivariate logistic regression analyses were undertaken to examine factors associated with patient-reported safety incidents.

RESULTS

Safety incidents were reported by 11% of the patients. Four factors were significantly associated with patient-reported safety incidents in multivariate analyses. The experience of multiple long-term conditions (OR=1.09, 95% CI 1.05 to 1.13), a probable diagnosis of depression (OR=1.36, 95% CI 1.06 to 1.74) and greater relational continuity of care (OR=1.28, 95% CI 1.08 to 1.52) were associated with increased odds for patient-reported safety incidents. Perceived greater support and involvement in self-management was associated with lower odds for patient-reported safety incidents (OR=0.95, 95% CI 0.93 to 0.97).

CONCLUSIONS

We found that older patients with multimorbidity and depression are more likely to report experiences of patient safety incidents. Improving perceived support and involvement of patients in their care may help prevent patient-reported safety incidents.

PReSaFe: A model of barriers and facilitators to patients providing feedback on experiences of safety

Objective

The importance of involving patients in reporting on safety is increasingly recognized. Whilst studies have identified barriers to clinician incident reporting, few have explored barriers and facilitators to patient reporting of safety experiences. This paper explores patient perspectives on providing feedback on safety experiences.

Design/Participants

Patients (n=28) were invited to take part in semi‐structured interviews when given a survey about their experiences of safety following hospital discharge. Transcripts were thematically analysed using NVivo10.

Setting

Patients were recruited from four hospitals in the UK.

Results

Three themes were identified as barriers and facilitators to patient involvement in providing feedback on their safety experiences. The first, cognitive‐cultural, found that whilst safety was a priority for most, some felt the term was not relevant to them because safety was the “default” position, and/or because safety could not be disentangled from the overall experience of care. The structural‐procedural theme indicated that reporting was facilitated when patients saw the process as straightforward, but that disinclination or perceived inability to provide feedback was a barrier. Finally, learning and change illustrated that perception of the impact of feedback could facilitate or inhibit reporting.

Conclusions

When collecting patient feedback on experiences of safety, it is important to consider what may help or hinder this process, beyond the process alone. We present a staged model of prerequisite barriers and facilitators and hypothesize that each stage needs to be achieved for patients to provide feedback on safety experiences. Implications for collecting meaningful data on patients' safety experiences are considered.

Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study

OBJECTIVE

To develop and validate a mechanism for patients to provide feedback on safety experiences following a care transfer between organisations.

DESIGN

Qualitative study using participatory methods (codesign workshops) and cognitive interviews. Workshop data were analysed concurrently with participants, and cognitive interviews were thematically analysed using a deductive approach based on the developed feedback mechanism.

PARTICIPANTS

Expert patients (n=5) and healthcare professionals (n=11) were recruited purposively to develop the feedback mechanism in 2 workshops. Workshop 1 explored principles underpinning safety feedback mechanisms, and workshop 2 included the practical development of the feedback mechanism. Final design and content of the feedback mechanism (a safety survey) were verified by workshop participants, and cognitive interviews (n=28) were conducted with patients.

RESULTS

Workshop participants identified that safety feedback mechanisms should be patient-centred, short and concise with clear signposting on how to complete, with an option to be anonymous and balanced between positive (safe) and negative (unsafe) experiences. The agreed feedback mechanism consisted of a survey split across 3 stages of the care transfer: departure, journey and arrival. Care across organisational boundaries was recognised as being complex, with healthcare professionals acknowledging the difficulty implementing changes that impact other organisations. Cognitive interview participants agreed the content of the survey was relevant but identified barriers to completion relating to the survey formatting and understanding of a care transfer.

CONCLUSIONS

Participatory, codesign principles helped overcome differences in understandings of safety in the complex setting of care transfers when developing a safety survey. Practical barriers to the survey's usability and acceptability to patients were identified, resulting in a modified survey design. Further research is required to determine the usability and acceptability of the survey to patients and healthcare professionals, as well as identifying how governance structures should accommodate patient feedback when relating to multiple health or social care providers.

Patient and public involvement in patient safety research: a workshop to review patient information, minimise psychological risk and inform research

PLAIN ENGLISH SUMMARY

Patient safety is a growing research area. However, although patients and the public are increasingly involved in clinical research, there is little guidance on how best to involve patients in patient safety research. Here we focus on how patients can contribute to the design of patient safety research. We conducted a workshop with patients as part of a project exploring errors and safety in the delivery of intravenous medication (medication given via a vein). The workshop was designed to explore how best to engage with hospital inpatients about these issues, to generate research topics, and to inform researchers about patients' experiences. Nine patients participated, each of whom had previously received intravenous medication. Participants advised against using terms such as 'error'; they also advocated caution when using terms such as 'safety' when describing the study to patients as this may worry some who had not thought about these issues before. We received thorough and useful feedback on our patient information sheets to ensure they were clear and understandable to patients. Patients also shared rich experiences with us about their treatment, which emphasised the need to extend our research focus to include a wider range of factors affecting quality and safety.

ABSTRACT

Background Patient safety has attracted increasing attention in recent years. This paper explores patients' contributions to informing patient safety research at an early stage, within a project on intravenous infusion errors. Currently, there is little or no guidance on how best to involve patients and the wider public in shaping patient safety research, and indeed, whether such efforts are worthwhile. Method We ran a 3-hour workshop involving nine patients with experience of intravenous therapy in the hospital setting. The first part explored patients' experiences of intravenous therapy. We derived research questions from the resulting discussion through qualitative analysis. In the second part, patients were asked for feedback on patient information sheets considering both content and clarity, and on two potential approaches to framing our patient information: one that focused on research on safety and error, the other on quality improvement. Results The workshop led to a thorough review of how we should engage with patients. Importantly, there was a clear steer away from terms such as 'error' and 'safety' that could worry patients. The experiences that patients revealed were also richer than we had anticipated, revealing different conceptions of how patients related to their treatment and care, their role in safety and use of medical devices, the different levels of information they preferred, and broader factors impacting perceptions of their care. Conclusion Involving patients at an early stage in patient safety research can be of great value. Our workshop highlighted sensitivities around potentially worrying patients about risks that they might not have considered previously, and how to address these. Patient representatives also emphasised a need to expand the focus of patient safety research beyond clinicians and error, to include factors affecting perceptions of quality and safety for patients more broadly.