Responding to patient safety incidents: the "seven pillars"

Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration

OBJECTIVE

This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies.

BACKGROUND

In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies.

SEARCH STRATEGY AND INCLUSION CRITERIA

To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles.

MAIN RESULTS AND SYNTHESIS

The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support and desired outcomes.

PATIENT CONTRIBUTION

This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Healthcare Professional Experiences of Clinical Incident in Hong Kong: A Qualitative Study

BACKGROUND

Studies showed that adverse events within health care settings can lead to two victims. The first victim is the patient and family and the second victim is the involved healthcare professionals. However, there is a lack of research studying the experiences of healthcare professionals encountering clinical incidents in Hong Kong. This paper reports a qualitative study in exploring the healthcare professional experiences of clinical incident, their impacts and needs.

METHODS

This study is the second part of the mixed research method with two studies conducted in a cluster of hospitals in Hong Kong. Study 1 was a quantitative questionnaire survey and Study 2 was a qualitative In-Depth Interview. In study 2, a semi-interview guide was used.

RESULTS

Results showed that symptoms experienced after the clinical incident were mostly from psychological, physical, then social and lastly spiritual aspects which were consistent with those found in study 1 and other studies. Using content analysis for analyzing the impacts, four themes were identified. Concerning the impacts immediately from the clinical incident, two themes emerged were 1) facing emotion distress and 2) maintaining rationality. Regarding the impacts after the clinical incident, another two themes were 3) managing further emotional distress 4) restoring personal wellness. With regard to the needs after clinical incidents, three themes emerged were 1) self-recovery; 2) senior good mentoring and 3) positive organization climate with emphasis on enhancement of training and development of a positive practice culture.

CONCLUSION

Great impacts are found with healthcare professionals encountering clinical incidents from a holistic perspective. They need time for self-recovery with support from good supervisors, peers and a caring environment. Some recommendations based on the findings of the study are made.

Whose experience is it anyway? Toward a constructive engagement of tensions in patient-centered health care

Purpose

Healthcare delivery faces increasing pressure to move from a provider-centered approach to become more consumer-driven and patient-centered. However, many of the actions taken by clinicians, patients and organizations fail to achieve that aim. This paper aims to take a paradox-based perspective to explore five specific tensions that emerge from this shift and provides implications for patient experience research and practice.

Design/methodology/approach

This paper uses a conceptual approach that synthesizes literature in health services and administration, organizational behavior, services marketing and management and service operations to illuminate five patient experience tensions and explore mitigation strategies.

Findings

The paper makes three key contributions. First, it identifies five tensions that result from the shift to more patient-centered care: patient focus vs employee focus, provider incentives vs provider motivations, care customization vs standardization, patient workload vs organizational workload and service recovery vs organizational risk. Second, it highlights multiple theories that provide insight into the existence of the tensions and how they may be navigated. Third, specific organizational practices that engage the tensions and associated examples of leading organizations are identified. Relevant measures for research and practice are also suggested.

Originality/value

The authors develop a novel analysis of five persistent tensions facing healthcare organizations as a result of a shift to a more consumer-driven, patient-centered approach to care. The authors detail each tension, discuss an existing theory from organizational behavior or services marketing that helps make sense of the tension, suggest potential solutions for managing or resolving the tension and provide representative case illustrations and useful measures.

Open disclosure of adverse events: exploring the implications of service and policy structures on practice

Purpose

The aim of this study was to explore the service and policy structures that impact open disclosure (OD) practices in New South Wales (NSW), Australia.

Participants and methods

An explorative study using semi-structured interviews was undertaken with 12 individuals closely involved in the implementation of OD in hospitals at policy or practice levels within the state of NSW, Australia. Interviews explored the service and policy structures surrounding OD and the perceived impact of these on the implementation of the OD policy. These data were thematically analyzed to understand the factors facilitating and creating barriers to openness after adverse events.

Results

The data identified three key areas in which greater alignment between OD policy and the wider service and policy structures may enhance the implementation of OD practice: 1) alignment between OD and root cause analysis processes, 2) holistic training that links to other relevant processes such as communicating bad news, risk management, and professional regulation and insurance, and 3) policy clarification regarding the disclosure of incidents that result in no or low-level harm.

Conclusion

Evidence from this study indicates that formal OD processes are not routinely applied after adverse events in NSW, despite clear guidelines for OD. The reasons for this are unclear as the service-level and policy-level phenomena that support or hinder OD are understudied. This knowledge is critical to addressing the policy-practice gap. Our paper provides insights regarding the influence of current service-level and policy-level phenomena on the delivery of OD and how policy clarification may contribute to addressing some of the challenges for implementing OD policy. The principles of virtue ethics – specifically, openness and the involvement of service users – may contribute to progressing in this area.

Patient and family engagement in incident investigations: exploring hospital manager and incident investigators' experiences and challenges

Objective There is growing recognition among health care providers and policy makers that when things go wrong, the patient or their families should be heard and participate in the incident investigation process. This paper explores how Dutch hospitals organize patient or family engagement in incident investigations, maps out incident investigators' experiences of involving patients or their families in incident investigations and identifies the challenges encountered. Methods Semi-structured interviews were conducted with managers and incident investigators in 13 Dutch hospitals. Study participants (n = 18) were asked about the incident investigation routines and their experiences of involving affected patients or family members. Interview transcripts were coded and analysed using thematic content analysis. Results Our findings reveal that patient or family involvement in incident investigations is typically organized as a one-time interview event. Interviews with patients or their families were considered to be valuable and important in their own right and seen as a way to do justice to the individual needs of the patient or their family. Yet, the usefulness and validity of the patient or family perspective for incident investigations was often seen to be limited, with the professional perspective afforded more weight. This was particularly the case when the patient or their family were unable to provide verifiable details of the incident under investigation. Study participants described challenges when involving patients or family members, including in relation to the available timeframe for incident investigations, legal issues, managing trust and working with intense emotions. Conclusions We propose that by placing patient and family criteria of significance at the centre of incident investigations (i.e. an 'emic' research approach), hospitals may be able to expand their learning potential and improve patient-centeredness following an incident.

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient-doctor relationship

BACKGROUND

Patient advocates and safety experts encourage adoption of transparent health records, but sceptics worry that shared notes may offend patients, erode trust or promote defensive medicine. As electronic health records disseminate, such disparate views fuel policy debates about risks and benefits of sharing visit notes with patients through portals.

METHODS

Presurveys and postsurveys from 99 volunteer doctors at three US sites who participated in OpenNotes and postsurveys from 4592 patients who read at least one note and submitted a survey.

RESULTS

Patients read notes to be better informed and because they were curious; about a third read them to check accuracy. In total, 7% (331) of patients reported contacting their doctor's office about their note. Of these, 29% perceived an error, and 85% were satisfied with its resolution. Nearly all patients reported feeling better (37%) or the same (62%) about their doctor. Patients who were older (>63), male, non-white, had fair/poor self-reported health or had less formal education were more likely to report feeling better about their doctor. Among doctors, 26% anticipated documentation errors, and 44% thought patients would disagree with notes. After a year, 53% believed patient satisfaction increased, and 51% thought patients trusted them more. None reported ordering more tests or referrals.

CONCLUSIONS

Despite concerns about errors, offending language or defensive practice, transparent notes overall did not harm the patient-doctor relationship. Rather, doctors and patients perceived relational benefits. Traditionally more vulnerable populations-non-white, those with poorer self-reported health and those with fewer years of formal education-may be particularly likely to feel better about their doctor after reading their notes. Further informing debate about OpenNotes, the findings suggest transparent records may improve patient satisfaction, trust and safety.

Changes in Physician Practice Patterns after Implementation of a Communication-and-Resolution Program

OBJECTIVE

To test if a 2006 communication-and-resolution program to address unexpected adverse outcomes was associated with changes in cost and use trajectories.

DATA SOURCE

Records of patients discharged with a principal diagnosis of chest pain from 44 nonfederal general hospitals in Cook County, Illinois, between January 2002 and December 2009.

STUDY DESIGN

Propensity-score matched discharges from the intervention and comparison hospitals before computing difference-in-differences estimates of quarterly growth rates.

DATA COLLECTION METHODS

We used discharge records submitted to a central statewide repository.

PRINCIPAL FINDINGS

Relative to the comparison hospitals and to pre-implementation trends, and consistent with reduced testing at presentation, the intervention hospital recorded an increase in the number of patients with a principal diagnosis of chest pain. Among admitted patients, quarterly growth rates of clinical laboratory and radiology charges at the intervention hospital declined by 3.8 and 6.9 percentage points.

CONCLUSIONS

Among patients with chest pain, the implementation of a comprehensive communication-and-resolution program was associated with substantially reduced growth rates in the use of diagnostic testing and imaging services. Further research is needed to establish to what extent these changes were attributable to the program and clinically appropriate.

Progress at the Intersection of Patient Safety and Medical Liability: Insights from the AHRQ Patient Safety and Medical Liability Demonstration Program

OBJECTIVE

To identify lessons learned from the experience of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety and Medical Liability (PSML) Demonstration Program.

DATA SOURCES/STUDY SETTING

On September 9, 2009, President Obama directed the Secretary of Health and Human Services to authorize demonstration projects that put "patient safety first" with the intent of reducing preventable adverse outcomes and stemming liability costs. Seven demonstration projects received 3 years of funding from AHRQ in the summer of 2010, and the program formally came to a close in June 2015.

STUDY DESIGN

The seven grantees implemented complex, broad-ranging innovations addressing both patient safety and medical liability in "real-world" contexts. Some projects featured novel approaches, while others implemented adaptations of existing models. Each project was funded by AHRQ to collect data on the impact of its interventions. In addition, AHRQ funded a cross-cutting qualitative evaluation focused on lessons learned in implementing PSML interventions.

DATA COLLECTION/EXTRACTION METHODS

Site visits and follow-up interviews supplemented with material abstracted from formal project reports to AHRQ.

PRINCIPAL FINDINGS

The PSML demonstration projects focused on three broad approaches: (1) improving communication around adverse events through disclosure and resolution programs; (2) preventing harm through implementation of clinical "best practices"; and (3) exploring alternative methods of settling claims. Although the demonstration contributed to accumulating evidence that these kinds of interventions can positively affect outcomes, there is also evidence to suggest that these interventions can be difficult to scale.

CONCLUSIONS

In addition to producing at least preliminary positive outcomes, the demonstration also lends credence to the idea that targeted interventions that improve some aspect of patient safety or malpractice performance may also contribute more broadly to institutional culture and the alignment of all parties around reducing risk and preventing harm. However, more empirical work needs to be carried out to quantify the effect of such interventions.

The "Seven Pillars" Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes

OBJECTIVE

To determine whether a communication and resolution approach to patient harm is associated with changes in medical liability processes and outcomes.

DATA SOURCES/STUDY SETTING

Administrative, safety, and risk management data from the University of Illinois Hospital and Health Sciences System, from 2002 to 2014.

STUDY DESIGN

Single health system, interrupted time series design. Using Mann-Whitney U tests and segmented regression models, we compared means and trends in incident reports, claims, event analyses, patient communication consults, legal fees, costs per claim, settlements, and self-insurance expenses before and after the implementation of the "Seven Pillars" communication and resolution intervention.

DATA COLLECTION METHODS

Queried databases maintained by Department of Safety and Risk Management and the Department of Administrative Services at UIH. Extracted data from risk module of the Midas incident reporting system.

PRINCIPAL FINDINGS

The intervention nearly doubled the number of incident reports, halved the number of claims, and reduced legal fees and costs as well as total costs per claim, settlement amounts, and self-insurance costs.

CONCLUSIONS

A communication and optimal resolution (CANDOR) approach to adverse events was associated with long-lasting, clinically and financially significant changes in a large set of core medical liability process and outcome measures.

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement

The disclosure of adverse events to patients, including those caused by medical errors, is a critical part of patient-centered healthcare and a fundamental component of patient safety and quality improvement. Disclosure benefits patients, providers, and healthcare institutions. However, the act of disclosure can be difficult for physicians. Surgeons struggle with disclosure in unique ways compared with other specialties, and disclosure in the surgical setting has specific challenges. The frequency of surgical adverse events along with a dysfunctional tort system, the team structure of surgical staff, and obstacles created inadvertently by existing surgical patient safety initiatives may contribute to an environment not conducive to disclosure. Fortunately, there are multiple strategies to address these barriers. Participation in communication and resolution programs, integration of Just Culture principles, surgical team disclosure planning, refinement of informed consent and morbidity and mortality processes, surgery-specific professional standards, and understanding the complexities of disclosing other clinicians' errors all have the potential to help surgeons provide patients with complete, satisfactory disclosures. Improvement in the regularity and quality of disclosures after surgical adverse events and errors will be key as the field of patient safety continues to advance.

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

Background

In 2009 the UK National Patient Safety Agency relaunched its Being Open framework to facilitate the open disclosure of adverse events to patients in the NHS. The implementation of the framework has been, and remains, challenging in practice.

Aim

The aim of this work was to both critically evaluate and extend the current evidence base relating to open disclosure, with a view to supporting the implementation of a policy of open disclosure of adverse events in the NHS.

Methods

This work was conducted in three phases. The first phase comprised two focused systematic literature reviews, one summarising empirical research on the effectiveness of interventions to enhance open disclosure, and a second, broader scoping review, looking at reports of current opinion and practice and wider knowledge. The second phase involved primary qualitative research with the objective of generating new knowledge about UK-based stakeholders’ views on their role in and experiences of open disclosure. Stakeholder interviews were analysed using the framework approach. The third phase synthesised the findings from the first two phases to inform and develop a set of short pragmatic suggestions for NHS trust management, to facilitate the implementation and evaluation of open disclosure.

Results

A total of 610 papers met the inclusion criteria for the broad review. A large body of literature discussed open disclosure from a number of related, but sometimes conflicted, perspectives. Evidential gaps persist and current practice is based largely on expert consensus rather than evidence. There appears to be a tension between the existing pragmatic guidance and the more in-depth critiques of what being consistent and transparent in health care really means. Eleven papers met the inclusion criteria for the more focused review. There was little evidence for the effectiveness of disclosure alone on organisational or individual outcomes or of interventions to promote and support open disclosure. Interviews with stakeholders identified strong support for the basic principle of being honest with patients or relatives when someone was seriously harmed by health care. In practice however, the issues are complex and there is confusion about a number of issues relating to disclosure policies in the UK. The interviews generated insights into the difficulties perceived within health care at individual and institutional levels, in relation to fully implementing the Being Open guidance.

Conclusions

There are several clear strategies that the NHS could learn from to implement and sustain a policy of openness. Literature reviews and stakeholder accounts both identified the potential benefits of a culture that was generally more open (not just retrospectively open about serious harm). Future work could usefully evaluate the impact of disclosure on legal challenges within the NHS, best practice in models of support and training for open disclosure, embedding disclosure conversations in critical incident analysis and disclosure of less serious events.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

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.

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation

CONTEXT

The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few.

METHODS

Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states.

FINDINGS

We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles.

CONCLUSIONS

Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.

The heart of health care: parents' perspectives on patient safety

Behind the wall of silence in health care are the unanswered questions of parents whose children experienced harm at the hands of their caregivers. In an industry where information and communication are crucial to quality, parents' voices often go unheard. Although that has begun slowly to change, providers could benefit from following the HEART model of service recovery, which includes hearing the concerns of patients and their families, empathizing with them, apologizing when care goes wrong, responding to parents' concerns with openness, and thanking the patient and family.

Successful remediation of patient safety incidents: a tale of two medication errors

BACKGROUND

As patient safety acquires strategic importance for all stakeholders in the health care delivery chain, one promising mechanism centers on the proactive disclosure of medical errors to patients. Yet, disclosure and apology alone will not be effective in fully addressing patients' concerns after an adverse event unless they are paired with a remediation component.

PURPOSE

The purpose of this study was to identify key features of successful remediation efforts that accompany the proactive disclosure of medical errors to patients.

APPROACH

We describe and contrast two recent and very similar cases of preventable medical error involving inappropriate medication at a large tertiary-care academic medical center in the Midwestern United States.

FINDINGS

Despite their similarity, the two medical errors led to very different health outcomes and remediation trajectories for the injured patients. Although one error causing no permanent harm was mismanaged to the lasting dissatisfaction of the patient, the other resulted in the death of the patient but was remediated to the point of allowing the family to come to terms with the loss and even restored a modicum of trust in the providers' sincerity.

PRACTICE IMPLICATIONS

To maximize the opportunities for successful remediation, as soon as possible after the incident, providers should pledge to injured patients and their relatives that they will assist and accompany them in their recovery as long as necessary and then follow through on their pledge. As the two case studies show, it takes training and vigilance to ensure adherence to these principles and reach an optimal outcome for patients and their relatives.

An assessment of an educational intervention on resident physician attitudes, knowledge, and skills related to adverse event reporting

OBJECTIVE

Reporting and learning from events linked to patient harm and unsafe conditions is critical to improving patient safety. Programs that engage resident physicians in adverse event reporting can enhance patient safety and simultaneously address all 6 Accreditation Council for Graduate Medical Education competencies. Yet fewer than 60% of physicians know how to report adverse events and near misses, and fewer than 40% know what to report. Our study evaluated the effect of an educational intervention on anesthesiology residents' attitudes, knowledge, and skills related to adverse event reporting and the associated follow-up.

METHODS

In a prospective study, anesthesiology residents participated in a training program focused on the importance of reporting methods and on reporting adverse events for patient safety. Quarterly adverse event reports were analyzed retrospectively for 2 years before the intervention and prospectively for 7 quarters after the intervention. Residents also completed a survey, before and 1 year after the intervention, that evaluated their attitudes, experience, and knowledge regarding adverse event reporting.

RESULTS

After the intervention, the number of adverse event reports increased from 0 per quarter to almost 30 per quarter. We identified several categories of harm events, near misses, and unsafe conditions, including reports of disruptive providers. Of the harm events associated with invasive procedures, more than half were associated with lack of attending physician supervision. We also observed significant progress in the residents' ability to appropriately file a report, improved attitudes regarding the value of reporting and available emotional support, and a reduction in the perceived impediments to reporting.

CONCLUSIONS

An educational intervention increased the number of adverse event reports submitted by anesthesiology residents, improved their attitudes about the importance of reporting, and produced a source for learning opportunities and process improvements in the delivery of anesthesia care.