Communicating with patients about breakdowns in care: a national randomised vignette-based survey

Measuring how healthcare organizations respond after patients experience harm: perspectives and next steps

Patients can experience serious harm from healthcare, the impacts can be prolonged, and events may also affect families and clinicians. Communication and Resolution Programs (CRPs) are designed to reduce these negative impacts, rebuild trust, and improve patient safety, but are not consistently implemented. To inform implementation efforts, enable accountability, and promote innovation, it is critical to develop standardized performance measures assessing CRPs' structure, process, and outcomes. To advance CRP measurement, an interdisciplinary workgroup from the Pathway to Accountability, Compassion, and Transparency (PACT) Leadership and Innovation Network-a group of leading healthcare organizations with CRPs-explores meaningful approaches to measurement and proposes a set of next steps. Interested parties in CRP measurement prioritize developing person-centered outcome and experience measures; assessing equity; addressing clinician and organization concerns about how CRP measurement may affect reputational and legal risk; reducing the burden of measurement; and improving mechanisms for sharing data across organizations to promote transparency, accountability, and broader patient safety improvements. Recommended next steps include: build a national coalition of interested parties to guide the work; overcome barriers to measurement and improve feasibility, especially through the engagement of patient safety and risk management software vendors; explore measure development processes that focus on patient, family, and clinician-centered outcome and experience measures; define nationally recognized standardized CRP measures; consider the role for regulatory and financial incentives to promote their use; and facilitate data sharing and comparative analysis. Ongoing engagement and strategy will be essential to move CRP measurement forward.

Creating a Learning Health System for Improving Diagnostic Safety: Pragmatic Insights from US Health Care Organizations

OBJECTIVE

To identify challenges and pragmatic strategies for improving diagnostic safety at an organizational level using concepts from learning health systems METHODS: We interviewed 32 safety leaders across the USA on how their organizations approach diagnostic safety. Participants were recruited through email and represented geographically diverse academic and non-academic settings. The interview included questions on culture of reporting and learning from diagnostic errors; data gathering and analysis activities; diagnostic training and educational activities; and engagement of clinical leadership, staff, patients, and families in diagnostic safety activities. We conducted an inductive content analysis of interview transcripts and two reviewers coded all data.

RESULTS

Of 32 participants, 12 reported having a specific program to address diagnostic errors. Multiple barriers to implement diagnostic safety activities emerged: serious concerns about psychological safety associated with diagnostic error; lack of infrastructure for measurement, monitoring, and improvement activities related to diagnosis; lack of leadership investment, which was often diverted to competing priorities related to publicly reported measures or other incentives; and lack of dedicated teams to work on diagnostic safety. Participants provided several strategies to overcome barriers including adapting trigger tools to identify safety events, engaging patients in diagnostic safety, and appointing dedicated diagnostic safety champions.

CONCLUSIONS

Several foundational building blocks related to learning health systems could inform organizational efforts to reduce diagnostic error. Promoting an organizational culture specific to diagnostic safety, using science and informatics to improve measurement and analysis, leadership incentives to build institutional capacity to address diagnostic errors, and patient engagement in diagnostic safety activities can enable progress.

Speaking up about patient-perceived serious visit note errors: Patient and family experiences and recommendations

BACKGROUND

Open notes invite patients and families to read ambulatory visit notes through the patient portal. Little is known about the extent to which they identify and speak up about perceived errors. Understanding the barriers to speaking up can inform quality improvements.

OBJECTIVE

To describe patient and family attitudes, experiences, and barriers related to speaking up about perceived serious note errors.

METHODS

Mixed method analysis of a 2016 electronic survey of patients and families at 2 northeast US academic medical centers. Participants had active patient portal accounts and at least 1 note available in the preceding 12 months.

RESULTS

6913 adult patients (response rate 28%) and 3672 pediatric families (response rate 17%) completed the survey. In total, 8724/9392 (93%) agreed that reporting mistakes improves patient safety. Among 8648 participants who read a note, 1434 (17%) perceived ≥1 mistake. 627/1434 (44%) reported the mistake was serious and 342/627 (56%) contacted their provider. Participants who self-identified as Black or African American, Asian, "other," or "multiple" race(s) (OR 0.50; 95% CI (0.26,0.97)) or those who reported poorer health (OR 0.58; 95% CI (0.37,0.90)) were each less likely to speak up than white or healthier respondents, respectively. The most common barriers to speaking up were not knowing how to report a mistake (61%) and avoiding perception as a "troublemaker" (34%). Qualitative analysis of 476 free-text suggestions revealed practical recommendations and proposed innovations for partnering with patients and families.

CONCLUSIONS

About half of patients and families who perceived a serious mistake in their notes reported it. Identified barriers demonstrate modifiable issues such as establishing clear mechanisms for reporting and more challenging issues such as creating a supportive culture. Respondents offered new ideas for engaging patients and families in improving note accuracy.