Seeing it from both sides: do approaches to involving patients in improving their safety risk damaging the trust between patients and healthcare professionals? An interview study

A cross-sectional survey analysis of patient and family knowledge, confidence, and perceived barriers to reporting patient deterioration

BACKGROUND

The knowledge, confidence, and skills of healthcare consumers to identify acute clinical deterioration and appropriately escalate concerns remain largely undetermined. This gap is despite the widespread international introduction of consumer escalation systems intended to provide patients and family an avenue to escalate their concerns if worried about deterioration in their own or relative's condition during a hospital stay.

AIM

To explore patient and family knowledge of acute clinical deterioration, and their confidence and perceived barriers to escalating their concerns.

DESIGN

Cross-sectional, in-person, consumer surveys across an Australian acute adult hospital. The study specific survey tool was developed through a multistage process with healthcare consumer input during creation and testing.

METHODS

Questions explored healthcare consumer knowledge, confidence, and perceived barriers in association with acute clinical deterioration, recognising deterioration, and escalating concerns. Descriptive and inferential analysis was completed, and knowledge, confidence, and barrier scores established. Association between scores and consumer type, gender, age, education level, prior experience with clinical deterioration or rapid response team review, and hospitalisation history in the last 12 months were assessed using multivariable linear regression.

RESULTS

133 surveys were completed. Knowledge scores varied across respondents. Awareness of the local consumer escalation system was low. A positive association was identified between knowledge and confidence that diminished with increasing barrier scores. A strong negative correlation was present between barriers and confidence. No significant difference existed in knowledge, confidence, or barrier scores based on consumer type, gender, education level, previous experience with deterioration or rapid response team review, or hospitalisation history.

CONCLUSIONS

Limitations in patient and family knowledge may impede consumer escalation system success. Increasing knowledge may enhance patient and family confidence to identify deterioration and escalate concerns. However, barriers to consumer escalation decrease this potential. Interventions to increase consumer knowledge should therefore be accompanied by strategies to minimise barriers.

Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study

BACKGROUND

The management of acute deterioration following surgery remains highly variable. Patients and families can play an important role in identifying early signs of deterioration but effective contribution to escalation of care can be practically difficult to achieve. This paper reports the enablers and barriers to the implementation of patient-led escalation systems found during a process evaluation of a quality improvement programme Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND).

METHODS

The research used ethnographic methods, including over 100 hours of observations on surgical units in three English hospitals in order to understand the everyday context of care. Observations focused on the coordination of activities such as handovers and how rescue featured as part of this. We also conducted 27 interviews with a range of clinical and managerial staff and patients. We employed a thematic analysis approach, combined with a theoretically focused implementation coding framework, based on Normalisation Process Theory.

RESULTS

We found that organisational infrastructural support in the form of a leadership support and clinical care outreach teams with capacity were enablers in implementing the patient-led escalation system. Barriers to implementation included making changes to professional practice without discussing the value and legitimacy of operationalising patient concerns, and ensuring equity of use. We found that organisational work is needed to overcome patient fears about disrupting social and cultural norms.

CONCLUSIONS

This paper reveals the need for infrastructural support to facilitate the implementation of a patient-led escalation system, and leadership support to normalise the everyday process of involving patients and families in escalation. This type of system may not achieve its goals without properly understanding and addressing the concerns of both nurses and patients.

Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast

BACKGROUND

Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal.

METHODS

Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis.

RESULTS

We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents.

CONCLUSION

Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required.

Patient Voices in Hospital Safety during the COVID-19 Pandemic

Hospitalized patients and their families may be reluctant to express safety concerns. We aimed to describe safety and quality concerns experienced by hospitalized patients and families and factors and outcomes surrounding decisions about voicing concerns, including those related to the COVID-19 pandemic. We conducted semi-structured interviews with 19 discharged inpatients or family members in a qualitative descriptive design. Some participants reported concern about staff competency or knowledge, communication and coordination, potential treatment errors, or care environment. Factors influencing feeling safe included healthcare team member characteristics, communication and coordination, and safe care expectations. Reasoning for voicing concerns often included personal characteristics. Reasons for not voicing concerns included feeling no action was needed or the concern was low priority. Outcomes for voicing a concern were categorized as resolved, disregarded, and unknown. These findings support the vital importance of open safety communication and trustworthy response to patients and family members who voice concerns.

Engaging patients in patient safety: a qualitative study examining healthcare managers and providers' perspectives

BACKGROUND

Patients can play an essential role in improving patient safety by becoming actively involved in their health care. The present study aimed to qualitatively explore healthcare providers' (HCPs) and managers' perceptions on patient participation in patient safety processes.

METHODS

This qualitative study carried out in three teaching hospitals in Tehran, Iran. The data were collected through semi-structured interviews with 31 HCPs and managers working at public teaching hospitals, medical universities and the Ministry of Health. The data were analyzed using thematic analysis.

RESULTS

Three main themes and 21 sub-themes emerged from the interviews. Participants believed that patients and their families can play an effective role in maintaining and improving patient safety through different roles. However, a variety of barriers were identified at patients, providers, and system levels hindering patient participation in delivering safe care.

CONCLUSION

The participants identified facilitators and barriers to patient engagement in safety-orientated activities at multiple patients, providers, and system levels, indicating that complex, multifaceted initiatives must be designed to address the issue. This study encourages further research to enhance the understating of the problems and solutions to patient involvement in safety initiatives in the Iranian healthcare setting.

Improving the perception of respect for and the dignity of inpatients: a systematic review

OBJECTIVES

The aim of this systematic review is to find evidence to determine which strategies are effective for improving hospitalised patients' perception of respect and dignity.

METHODS

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The MEDLINE/PubMed, PsycINFO and Cochrane Library databases were searched on 9 March 2021. Observational studies, prospective studies, retrospective studies, controlled trials and randomised controlled trials with interventions focused on improving respect for patients and maintaining their dignity were included. Case reports, editorials, opinion articles, studies <10 subjects, responses/replies to authors, responses/replies to editors and review articles were excluded. The study population included inpatients at any health facility. Two evaluators assessed risk of bias according to the Cochrane Handbook of Systematic Reviews of Interventions criteria: allocation, randomisation, blinding and internal validity. The reviewers were blinded during the selection of studies as well as during the quality appraisal. Disagreements were resolved by consensus.

RESULTS

2515 articles were retrieved from databases and 44 articles were included in this review. We conducted a quality appraisal of the studies (27 qualitative studies, 14 cross-sectional studies, 1 cohort study, 1 quali-quantitative study and 1 convergent parallel mixed-method study).

DISCUSSION

A limitation of this study is that it may not be generalisable to all cultures. Most of the included studies are of good quality according to the quality appraisal. To improve medical and hospital care in most countries, it is necessary to improve the training of doctors and other health professionals.

CONCLUSION

Many strategies could improve the perception of respect for and the dignity of the inpatient. The lack of interventional studies in this field has led to a gap in knowledge to be filled with better designed studies and effect measurements.

PROSPERO REGISTRATION NUMBER

CRD42021241805.

Perspectives of Dental Patients About Safety Incident Reporting: A Qualitative Pilot Study

OBJECTIVES

Patient reporting of safety incidents is one of the hallmarks of an effective patient safety protocol in any health care setting. However, very little is known about safety reporting among dental patients or effective strategies for engaging them in activities that promote safety. The goal of this study was to understand the perceptions of dental patients about the barriers and benefits of reporting safety incidents. We also sought to identify strategies for improving patient reporting of safety incidents in the dental care setting.

METHODS

We conducted 3 focus group sessions with adult dental patients (n = 16) attending an academic dental center from November 2017 to February 2018. Audio recordings were transcribed and analyzed using a hybrid thematic analysis approach with NVivo software.

RESULTS

Dental patients mainly attributed safety incidents to provider-related and systemic factors. They were most concerned about the financial implications, inconvenience of multiple visits, and the absence of an apology when an incident occurred. The major recommended strategies for engaging patients in safety-related activities included the following: proactive solicitation of patient feedback, what-to-expect checklists, continuous communication during visits/procedures, after-visit summary reports, clear incident reporting protocols, use of technology, independent third-party safety incident reporting platforms, and a closed feedback loop.

CONCLUSIONS

This study offers a roadmap for proactively working with dental patients as vigilant partners in promoting quality and safety. If properly engaged, dental patients are prepared to work with dental professionals to identify threats to safety and reduce the occurrence of harm.

Barriers and facilitators to patient engagement in patient safety from patients and healthcare professionals' perspectives: A systematic review and meta-synthesis

AIMS

To explore patients' and healthcare professionals' (HCPs) perceived barriers and facilitators to patient engagement in patient safety.

METHODS

We conducted a systematic review and meta-synthesis from five computerized databases, including PubMed/MEDLINE, Embase, Web of Science, Scopus and PsycINFO, as well as grey literature and reference lists of included studies. Data were last searched in December 2019 with no limitation on the year of publication. Qualitative and Mix-methods studies that explored HCPs' and patients' perceptions of barriers and facilitators to patient engagement in patient safety were included. Two authors independently screened the titles and the abstracts of studies. Next, the full texts of the screened studies were reviewed by two authors. Potential discrepancies were resolved by consensus with a third author. The Mixed Methods Appraisal Tool was used for quality appraisal. Thematic analysis was used to synthesize results.

RESULTS

Nineteen studies out of 2616 were included in this systematic review. Themes related to barriers included: patient unwillingness, HCPs' unwillingness, and inadequate infrastructures. Themes related to facilitators were: encouraging patients, sharing information with patients, establishing trustful relationship, establishing patient-centred care and improving organizational resources.

CONCLUSION

Patients have an active role in improving their safety. Strategies are required to address barriers that hinder or prevent patient engagement and create capacity and facilitate action.

Pre-induction checklists and discomfort in patients. An observational study

BACKGROUND

Since the WHO release of the Safe Surgery Saves Lives Program in 2008, peri-operative checklists minimise errors and improve patient safety worldwide. Anaesthesia professionals are often reluctant to use these checklists in front of patients because they fear causing patients' discomfort before anaesthesia and surgery.

OBJECTIVE

To assess and compare the subjective level of patient discomfort caused by the use of pre-induction checklists with the patient discomfort estimated by anaesthesia providers.

DESIGN

Prospective observational study.

SETTING

The current single-centre trial included 110 anaesthesia providers and 125 nonpremedicated ear, nose and throat or maxillofacial surgery patients in Switzerland from June to August 2016. Inclusion criterion: signed general research consent.

EXCLUSION CRITERIA

received premedication, less than 18 years old, day-care patients, dementia or other mental illnesses.

INTERVENTIONS

Anaesthesia healthcare providers and patients before surgery and on the first postoperative day were asked to rate three statements: MAIN OUTCOME MEASURES: All statements were rated on a 100-mm visual analogue scale, where 0 meant no agreement and 100 meant total agreement.

RESULTS

Patients overwhelmingly agreed that anaesthesia providers should use checklists in front of them. Anaesthesia providers rated the patient discomfort much higher than actually perceived by patients. Both, patients and anaesthesia providers rated the possibility of reducing the risk of errors high.

CONCLUSION

Patients experience far less discomfort observing the use of pre-induction checklists than anaesthesia providers expect. Patients value the potential safety benefit significantly higher than anaesthesia providers. These results further support the implementation of peri-operative checklists in the operating room environment.

TRIAL REGISTRATION

The current observational study had no intervention, therefore, was not registered.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

FINDINGS

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

DISCUSSION

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

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals

BACKGROUND

When there is a gap in professionals' adherence to safe practices during cancer treatment, the consequences can be serious. Identifying these gaps in order to enable improvements in patient safety can be a challenge. This study aimed to assess if cancer patients and their relatives can be given the skills to audit reliably four safe practices, and to explore whether they are willing to play this new role.

METHODS

We recruited 136 participants in 2018, from the oncology and haematology day hospital of a tertiary hospital in Spain. Patient identification, hand hygiene, blood or chemotherapy identification, and side effects related to transfusion and chemotherapy, were the safe practices selected for evaluation. The study comprised two parts: an interventional educational program and a cross-sectional design to collect data and assess to what degree participants are able and willing to be auditors depending on their characteristics using multivariate logistic regression models. A participant's auditing skill were assessed pre and post the educational intervention.

RESULTS

The model was seeking predictors of being a good auditor. 63 participants (46.3%) were classified as good auditors after the training. To have younger age, higher educational level and to have had an experience of an adverse event were associated with a higher probability of being a good auditor. Additionally, 106 (77.9%) participants said that they would like to audit anonymously the professionals' compliance of at least three of four safe practices. The willingness to audit safe practices differed depending on the safe practice but these differences did not reach statistical significance.

CONCLUSIONS

The data gathered by patients and relatives acting as auditors can provide healthcare organizations with valuable information about safety and quality of care that is not accessible otherwise. This new role provides an innovative way to engage patients and their families' in healthcare safety where other methods have not had success. The paper sets out the methods that healthcare organizations need to undertake to enrol and train patients and relatives in an auditor role.

Patient and family involvement in escalating concerns about clinical deterioration in acute adult wards: A qualitative systematic review

BACKGROUND

Despite international standards for recognition and response to deterioration, warning signs are not always identified by staff on acute hospital wards. Patient and family-initiated escalation of care schemes have shown some benefit in assisting early recognition, but are not widely used in many clinical practice areas.

OBJECTIVES

To explore (a) patients' and relatives' experiences of acute deterioration and (b) patients', relatives' and healthcare professionals' perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We conducted a qualitative review using Cochrane methodology. Two reviewers independently screened studies, extracted data, and appraised the quality using a qualitative critical appraisal tool. Findings were analysed using thematic synthesis and confidence in findings was assessed using GRADE-CERQual.

SEARCH STRATEGY

MEDLINE, CINAHL, EMBASE, PsychINFO databases and grey literature from 2005 to August 2019.

INCLUSION CRITERIA

Any research design that had a qualitative element and focused on adult patients' and relatives' experiences of deterioration and perceptions of escalating care.

RESULTS

We included five studies representing 120 participants and assessed the certainty of evidence as moderate using GRADE-CERQual. Findings indicated that a number of patients/relatives have the ability to detect acute deterioration, however, various factors act as both barriers and facilitators to being heard. These include personal factors, perceptions of role, quality of relationships with healthcare staff, and organisational factors. Theoretical understanding suggests that patient and relative involvement in escalation is dependent on both inherent capabilities and the factors that influence empowerment.

CONCLUSION

This review highlights that patient and family escalation of care interventions need to be designed with the aim of improving patient/relative-clinician collaboration and the sharing of responsibility.

RELEVANCE TO PRACTICE

These factors need to be addressed to promote more active partnerships when designing and implementing patient and family-initiated escalation of care interventions.

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Mixed-method investigation of health consumers' perception and experience of participation in patient safety activities

OBJECTIVES

This study aimed to examine the factors influencing patient safety behaviours and to explore health customers' experiences of patient participation in the healthcare system.

DESIGN

A mixed-method sequential explanatory design was employed using a survey and focus group interviews with health consumers.

SETTING

The study was conducted in South Korea using an online survey tool.

PARTICIPANTS

Survey data were collected from 493 Korean adults, aged 19 years or older, who had visited hospitals within the most recent 1 year. Focus group interviews were conducted in two groups of six participants each among those of the survey participants who agreed to participate in focus groups.

MAIN OUTCOME MEASURES

The survey measured the recognition of the importance of participation, extent of willingness to participate and experience of engaging in patient safety activities using a 4-point Likert scale. Qualitative data were collected through focus group interviews to explore health consumers' experience of patient participation in hospital care, and the data were analysed using content analysis.

RESULTS

The average score for experience of participation in patient safety behaviours (2.13±0.63) was found to be lower than those of recognition of the importance of participation (3.27±0.51) and willingness to participate (2.62±0.52). By integrating the results of the quantitative and qualitative data analysis, the factors associated with the experience of engaging in healthcare behaviour included patient-related factors, illness-related factors, factors involving relationship between patients and healthcare providers, and healthcare environment factors.

CONCLUSIONS

To improve patient participation, it is necessary to create a healthcare environment in which patients can speak comfortably and to provide an education programme reflecting the patients' needs. Also, healthcare providers must consider patients as partners for patient safety. Shared decision-making procedures and patient-centred care and patient safety policies should be established in hospitals.

[Participation of patients in healthcare security: a systematic review]

The scope of this article was to identify the strategies used for the participation of the patient in healthcare security in hospital and outpatient environments. It involved a systematic review of the literature based on the recommendations of the PRISMA model on the Scopus, WOS and Medline databases. The search was restricted to studies written in Portuguese, English or Spanish conducted between January 2001 and July 2016. Observational, descriptive, qualitative and/or epidemiological studies that described a development/appliance methodology using at least one patient security improvement strategy of inclusion were included. The methodological quality of the studies was assessed using the randomized Cochrane risk-of-bias tool. Thematic analyses were performed in order to analyze the results. After the application of criteria of title, abstract analysis and exclusion, 19 studies were selected. In these studies, patient security strategies that promoted patients' active participation on patient security and information request strategies were identified. In the literature, sundry strategies promoting patient participation on healthcare security, with concrete implementation methods, as well as distinct purposes for their use, were encountered.

Patients' Perspectives of Surgical Safety Before and After Their Elective Surgeries at King Abdulaziz University Hospital, Jeddah, Saudi Arabia

Background Patients need to be educated and all possible treatment alternatives should be explored. Patients should be given options that they can choose from based on their demographic information, clinical information, and possible options for treating a given issue. This is especially true in elective surgery. The concept of safety plays a major part in every field, particularly in medicine. The patient's safety is a key factor for a better experience and a better outcome.  Objective This study aims to determine patient perceptions of surgical safety with an emphasis on surgical team interaction throughout the phases of care. Methods A descriptive cross-sectional prospective study was conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients undergoing elective surgery and hospitalized for more than 24 hours were asked to give their opinions regarding interactions between them and the surgical teams, including the nurses, anesthesiologists, and surgeons who operated on them. Only patients aged 18 or above were included in the sample. The analysis was carried out using the IBM Statistical Package for Social Sciences (SPSS), version 25 (IBM SPSS Statistics, Armonk, NY). Results More than 70% of the study respondents had had more than one surgery. One hundred and ten of the study respondents said that the specific surgeons who attended to them encouraged them to ask questions. The majority of the respondents (76.7%) said that the surgical team gave them definite physical comfort, while the rest (23.3%) stated that they got somewhat less physical comfort from the surgical team. The average rating of the satisfaction pre-surgery was mean (M) = 8.51, standard deviation (SD) = 1.9, (95% confidence interval (CI): 8.19 - 8.83) while the average satisfaction rating for postoperative care was M = 9.05, SD = 1.35, (95% CI: 8.82 - 9.27). Conclusions Most patients valued surgeon-patient interaction as it was seen to reduce pre-surgery anxiety, helped in giving options, and improved the patient's overall understanding of the surgical procedure. Surgical teams are generally highly rated in terms of overall service pre- and post-surgery.

Can patients contribute to safer care in meetings with healthcare professionals? A crosssectional survey of patient perceptions and beliefs

OBJECTIVES

To investigate patients' perceptions of their meetings with healthcare professionals and the extent to which they believe they can influence patient safety in these meetings.

DESIGN

Cross-sectional survey of patients using a study-specific questionnaire. Data were analysed using both parametric and non-parametric statistics.

SETTING

The study was conducted in primary and secondary care in three county councils in southeast Sweden by means of a survey questionnaire despatched in January 2017.

PARTICIPANTS

Survey data were collected from 1445 patients, 333 of whom were complainants (patients who had filed a complaint about being harmed in healthcare) and 1112 regular patients (patients recruited from healthcare units).

MAIN OUTCOME MEASURES

Patients' perceptions of meetings with physicians and nurses, beliefs concerning patients' contributions to safer care and whether the patients had suffered harm in healthcare during the past 10 years.

RESULTS

Most respondents reported that it was easy to ask physicians and nurses questions (84.9% and 86.6%) and to point out if something felt odd in their care (77.7% and 80.7%). In general, complainants agreed to a higher extent compared with regular patients that patients can contribute to safer care (mean 1.92 and 2.13, p<0.001). Almost one-third (31.2%) of the respondents (both complainants and regular patients) reported that they had suffered harm in healthcare during the past 10 years.

CONCLUSIONS

Most respondents believed that healthcare professionals can facilitate patient interaction and increase patient safety by encouraging patients to ask questions and take an active part in their care. Further research will need to identify strategies to support such questioning in routine practice and ensure that it achieves its intended goals.

The impact of patient-physician alliance on trust following an adverse event

OBJECTIVE

Adverse events in maternity care have a negative impact on the patient-physician relationship. This study assesses the effects of healthcare institutions, communication, and patient involvement on patient trust following adverse events.

METHODS

Surveys were distributed online to women across the US who had given birth. Women were asked to recount their experiences during their most recent pregnancy including unexpected procedures, adverse events, support from healthcare institutions, and perceived betrayals by healthcare institutions.

RESULTS

Adverse events were negatively correlated with patient trust in their physician. This study's results illustrated that patient involvement and institutional betrayal mediated patient trust following adverse events. Patients who were more involved in decision-making with their physician were found to have more trust in them following adverse events than those who did not.

CONCLUSIONS

Patient-physician trust is negatively affected by adverse events, but patient-physician alliance in decision-making can decrease this impact. Therefore, physicians can work proactively to lessen the detrimental effects of adverse events on patient trust, but the patient-physician relationship is still impacted by healthcare institutions.

PRACTICE IMPLICATIONS

This study demonstrates the benefits of encouraging patient alliance with their physician and supports a need for education on the use of these strategies in healthcare.

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.

Written reports of adverse events in acute care-A discourse analysis

Adverse health care events are a global public health issue despite major efforts, and they have been acknowledged as a complex concern. The aim of this study was to explore the construction of unsafe care using accounts of adverse events concerning the patient, as reported by patients, relatives, and health care professionals. Twenty-nine adverse events reported in an acute care setting in a Swedish university hospital were analyzed through discourse analysis, where the construction of what was considered to be real and true in the descriptions of unsafe care was analyzed. In the written reports about unsafe events, the patient was spoken of in three different ways: (a) the patient as a presentation of physical signs, (b) the patient as suffering and vulnerable, and (c) the patient as unpredictable. When the patient's voice was subordinate to physical signs, this was described as being something that conflicted with patient safety. The conclusion was that the patient's voice might be the only sign available in the early stages of adverse events. Therefore, it is crucial for health care professionals to give importance to the patient's voice to prevent patients from harm and not unilaterally act only upon abnormal physical signs.

The contribution of ethnography to the evaluation of quality improvement in hospital settings: reflections on observing co-design in intensive care units and lung cancer pathways in the UK

Ethnography is increasingly being used in the evaluation of quality improvement and change initiatives in healthcare settings, particularly in the form of 'focused' and 'rapid' ethnographies. This new ethnographic genre is tailored to suit narrower enquiries within clinical pathways. However, the application of ethnography to the evaluation of quality improvement is not straightforward or free from reductionist bias, particularly in hospital settings where interventions take place during a limited period of time and instigate change in busy and sensitive settings. This paper discusses problems and emergent solutions involved in conducting an ethnographic process evaluation of co-design projects in lung cancer and intensive care unit services in two hospitals in England. The mixed-methods ethnographic evaluation consisted of observations of the co-design process and triangulation of findings with interviews, questionnaires, participant reflective diaries and service improvement logs. Limitations of observational time and distance from 'the field' were overcome by making most of the pre- and post-event observational periods, situating quality improvement within the wider context of clinical practice, achieving attunement with local clinical cultures and engaging participants in collaboratively guiding observational and interview design. This approach led to a focused ethnographic evaluation that accommodated ethnographic principles to obtain rich insights into quality improvement processes despite the limitations of short-timeframes and the hospital setting.

The impact of status and social context on health service co-design: an example from a collaborative improvement initiative in UK primary care

BACKGROUND

Increasingly, collaborative participatory methods requiring open and honest interaction between a range of stakeholders are being used to improve health service delivery. To be successful these methodologies must incorporate perspectives from a range of patients and staff. Yet, if unaccounted for, the complex relationships amongst staff groups and between patients and providers can affect the veracity and applicability of co-designed solutions.

METHODS

Two focus groups convened to discuss suggestions for the improvement of blood testing and result communication in primary care. The groups were mixed of patients and staff in various combinations drawn from the four participating study practices. Here we present a secondary mixed-method analysis of the interaction between participants in both groups using sociogrammatic and thematic analysis.

RESULTS

Despite a similar mix of practice staff and patients the two groups produced contrasting discussions, seemingly influenced by status and social context. The sociograms provided a useful insight into the flow of conversation and highlighted the dominance of the senior staff member in the first focus group. Within the three key themes of social context, the alliances formed between participants and the fluidity of the roles assumed manifested differently between groups apparently dictated by the different profile of the participants of each.

CONCLUSIONS

For primary care service improvement attention must be paid to the background of participants when convening collaborative service improvement groups as status and imported hierarchies can have significant connotations for the data produced.

'It's sometimes hard to tell what patients are playing at': How healthcare professionals make sense of why patients and families complain about care

This article draws from sociological and socio-legal studies of dispute between patients and doctors to examine how healthcare professionals made sense of patients' complaints about healthcare. We analyse 41 discursive interviews with professional healthcare staff working in eight different English National Health Service settings to explore how they made sense of events of complaint and of patients' (including families') motives for complaining. We find that for our interviewees, events of patients' complaining about care were perceived as a breach in fundamental relationships involving patients' trust or patients' recognition of their work efforts. We find that interviewees rationalised patients' motives for complaining in ways that marginalised the content of their concerns. Complaints were most often discussed as coming from patients who were inexpert, distressed or advantage-seeking; accordingly, care professionals hearing their concerns about care positioned themselves as informed decision-makers, empathic listeners or service gate-keepers. We find differences in our interviewees' rationalisation of patients' complaining about care to be related to local service contingences rather than to fixed professional differences. We note that it was rare for interviewees to describe complaints raised by patients as grounds for improving the quality of care. Our findings indicate that recent health policy directives promoting a view of complaints as learning opportunities from critical patient/consumers must account for sociological factors that inform both how the agency of patients is envisaged and how professionalism exercised contemporary healthcare work.

Determinants of patient participation for safer care: A qualitative study of physicians' experiences and perceptions

OBJECTIVE

There is a paucity of research on physicians' perspectives on involving patients to achieve safer care. This study aims to explore determinants of patient participation for safer care, according to physicians in Swedish health care.

METHODS

We used a deductive descriptive design, applying qualitative content analysis based on the Capability-Opportunity-Motivation-Behaviour framework. Semi-structured interviews were conducted with 13 physicians in different types of health care units, to achieve a heterogeneous sample. The main outcome measure was barriers and facilitators to patient participation of potential relevance for patient safety.

RESULTS

Analysis of the data yielded 14 determinants (ie, subcategories) functioning as barriers and/or facilitators to patient participation of potential relevance for patient safety. These determinants were mapped to five categories: physicians' capability to involve patients in their care; patients' capability to become involved in their care, as perceived by the physicians; physicians' opportunity to achieve patient participation in their care; physicians' motivation to involve patients in their care; and patients' motivation to become involved in their care, as perceived by the physicians.

CONCLUSION

There are many barriers to patient participation to achieve safer care. There are also facilitators, but these tend to depend on initiatives of individual physicians and patients, because organizational-level support may be lacking. Many of the determinants are interdependent, with physicians' perceived time constraints influencing other barriers.

Patient-mediated interventions to improve professional practice

BACKGROUND

Healthcare professionals are important contributors to healthcare quality and patient safety, but their performance does not always follow recommended clinical practice. There are many approaches to influencing practice among healthcare professionals. These approaches include audit and feedback, reminders, educational materials, educational outreach visits, educational meetings or conferences, use of local opinion leaders, financial incentives, and organisational interventions. In this review, we evaluated the effectiveness of patient-mediated interventions. These interventions are aimed at changing the performance of healthcare professionals through interactions with patients, or through information provided by or to patients. Examples of patient-mediated interventions include 1) patient-reported health information, 2) patient information, 3) patient education, 4) patient feedback about clinical practice, 5) patient decision aids, 6) patients, or patient representatives, being members of a committee or board, and 7) patient-led training or education of healthcare professionals.

OBJECTIVES

To assess the effectiveness of patient-mediated interventions on healthcare professionals' performance (adherence to clinical practice guidelines or recommendations for clinical practice).

SEARCH METHODS

We searched MEDLINE, Ovid in March 2018, Cochrane Central Register of Controlled Trials (CENTRAL) in March 2017, and ClinicalTrials.gov and the International Clinical Trials Registry (ICTRP) in September 2017, and OpenGrey, the Grey Literature Report and Google Scholar in October 2017. We also screened the reference lists of included studies and conducted cited reference searches for all included studies in October 2017.

SELECTION CRITERIA

Randomised studies comparing patient-mediated interventions to either usual care or other interventions to improve professional practice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data and assessed risk of bias. We calculated the risk ratio (RR) for dichotomous outcomes using Mantel-Haenszel statistics and the random-effects model. For continuous outcomes, we calculated the mean difference (MD) using inverse variance statistics. Two review authors independently assessed the certainty of the evidence (GRADE).

MAIN RESULTS

We included 25 studies with a total of 12,268 patients. The number of healthcare professionals included in the studies ranged from 12 to 167 where this was reported. The included studies evaluated four types of patient-mediated interventions: 1) patient-reported health information interventions (for instance information obtained from patients about patients' own health, concerns or needs before a clinical encounter), 2) patient information interventions (for instance, where patients are informed about, or reminded to attend recommended care), 3) patient education interventions (intended to increase patients' knowledge about their condition and options of care, for instance), and 4) patient decision aids (where the patient is provided with information about treatment options including risks and benefits). For each type of patient-mediated intervention a separate meta-analysis was produced.Patient-reported health information interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 26 (95% CI 23 to 30) are in accordance with recommended clinical practice compared to 17 per 100 in the comparison group (no intervention or usual care). We are uncertain about the effect of patient-reported health information interventions on desirable patient health outcomes and patient satisfaction (very low-certainty evidence). Undesirable patient health outcomes and adverse events were not reported in the included studies and resource use was poorly reported.Patient information interventions may improve healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 42) are in accordance with recommended clinical practice compared to 20 per 100 in the comparison group (no intervention or usual care). Patient information interventions may have little or no effect on desirable patient health outcomes and patient satisfaction (low-certainty evidence). We are uncertain about the effect of patient information interventions on undesirable patient health outcomes because the certainty of the evidence is very low. Adverse events and resource use were not reported in the included studies.Patient education interventions probably improve healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We found that for every 100 patients consulted or treated, 46 (95% CI 39 to 54) are in accordance with recommended clinical practice compared to 35 per 100 in the comparison group (no intervention or usual care). Patient education interventions may slightly increase the number of patients with desirable health outcomes (low-certainty evidence). Undesirable patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.Patient decision aid interventions may have little or no effect on healthcare professionals' adherence to recommended clinical practice (low-certainty evidence). We found that for every 100 patients consulted or treated, 32 (95% CI 24 to 43) are in accordance with recommended clinical practice compared to 37 per 100 in the comparison group (usual care). Patient health outcomes, patient satisfaction, adverse events and resource use were not reported in the included studies.

AUTHORS' CONCLUSIONS

We found that two types of patient-mediated interventions, patient-reported health information and patient education, probably improve professional practice by increasing healthcare professionals' adherence to recommended clinical practice (moderate-certainty evidence). We consider the effect to be small to moderate. Other patient-mediated interventions, such as patient information may also improve professional practice (low-certainty evidence). Patient decision aids may make little or no difference to the number of healthcare professionals' adhering to recommended clinical practice (low-certainty evidence).The impact of these interventions on patient health and satisfaction, adverse events and resource use, is more uncertain mostly due to very low certainty evidence or lack of evidence.

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.

Are Parents Who Feel the Need to Watch Over Their Children's Care Better Patient Safety Partners?

OBJECTIVES

Many parents report needing to watch over their child's hospital care to prevent mistakes. In this study, we assessed whether needing to watch over care predicts parent performance of recommended safety behaviors to reduce medication errors and health care-associated infections.

METHODS

At admission, we surveyed 170 parents about their need to watch over care, demographics, and hospitalization factors. At discharge, parents were surveyed about medication awareness and hand hygiene behaviors. Logistic regression was used to examine how parents' need to watch over care predicted each behavior, adjusting for demographics and hospitalization factors.

RESULTS

Thirty-eight percent of parents reported needing to watch over care. Most parents (77%) reported frequently or very frequently asking providers for drug names or doses. Fewer parents asked to check drug or infusion accuracy (29%) or to show or read aloud medication labels (21%). Few parents reminded providers to clean hands (4%), but most stated they would be comfortable asking (82%) and likely to speak up if a provider did not (78%). After adjustment, parents needing to watch over care were significantly more likely to ask providers to check drug or infusion accuracy (adjusted odds ratio = 4.59, 95% confidence interval 2.14-9.94) and for drug name or dose (adjusted odds ratio = 3.04, 95% confidence interval 1.25-7.39).

CONCLUSIONS

Parents who report the need to watch over care are more likely to perform behaviors specific to safe medication use (but not hand hygiene) compared with those not reporting this need. Opportunities exist to engage parents as safety partners by leveraging their need to watch over care toward system-level safety initiatives.

The Effect of Education on Parents' "Speak Up" Knowledge Regarding Patients Safety in Hospital

Introduction: Safety is a global issue in hospitals. Unexpected events or errors related to health services occur in children, and about 75% are associated with medical procedures. Parental involvement becomes one of the strategies used to improve patient safety. Families who know patient safety can educate themselves to prevent and detect errors that occur during treatment. Education can improve the general knowledge about patient safety. The Speak Up program is recommended by JCAHO to improve effective communication, and this program has a preventive impact on human error. This study aims to determine the effect of education on parent’s ‘speaking up’ knowledge regarding patient safety in the Children's Wards of Dr. Sardjito Hospital in Yogyakarta.Methods: This research study was quasi-experimental using a one group pre-test and post-test design. The intervention in this research was education. The consecutive sampling technique was used with a total of 62 respondents selected. The Speak Up questionnaire and observation sheet to get to know the changes in the knowledge of Speak Up was used to collect the data. The data analysis used a Paired Sample T-Test.Result: The result of the paired T-test showed a p-value <0,001 (p <0,05) which means that there was a significant influence by way of education on parent’s speak up knowledge regarding patient safety.Conclusion: Education improved the parents' speak up knowledge about patient safety.

Working for patient safety: a qualitative study of women's help-seeking during acute perinatal events

BACKGROUND

Women and their relatives can play an important role in early detection and help seeking for acute perinatal events. Recent UK reports indicate that patient-professional partnership in 'working for safety' can be difficult to achieve in practice, sometimes with catastrophic consequences. This research explored the experiences of women and relatives who had experienced early warning signs about their condition and sought help in escalating care.

METHODS

Secondary analysis of case study data which included qualitative interviews with 22 women purposively sampled on account of experiencing a step up in care and 4 of their relatives from two NHS Trusts in England during 2010. Analysis focused on the type of safety work participants engaged in, and the opportunities and challenges reported by women and family members when negotiating safety at home and in hospital.

RESULTS

Women and relatives took on a dual responsibility for self-diagnosis, self-care and seeking triage, whilst trying to avoid overburdening stretched services. Being informed, however, did not necessarily enable engagement from staff and services. The women's narratives highlighted the work that they engaged in to build a case for clinical attention, the negotiations that took place with health care professionals and the strategies women and partners drew on (such as objective signs and symptoms, use of verbal insistence and repetition) to secure clinical help. For some women, the events left them with a lasting feeling that their concerns had been disregarded. Some described a sense of betrayal and loss of trust in an institution they believed had failed to care for them.

CONCLUSION

The notion of 'safety partnerships' which suggests a sense of equality and reciprocity was not borne out by our data, especially with regards to the experiences of teenage women. To enable women and families to secure a rapid response in clinical emergencies, strategies need to move beyond the provision of patient information about warning signs. Effective partnerships for safety may be supported by system level change such as improved triage, continuity of care, self-referral pathways and staff training to address asymmetries of power that persist within the health system.

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.

A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships

BACKGROUND

OpenNotes, a national movement inviting patients to read their clinicians' notes online, may enhance safety through patient-reported documentation errors.

OBJECTIVE

To test an OpenNotes patient reporting tool focused on safety concerns.

METHODS

We invited 6225 patients through a patient portal to provide note feedback in a quality improvement pilot between August 2014 and 2015. A link at the end of the note led to a 9-question survey. Patient Relations personnel vetted responses, shared safety concerns with providers and documented whether changes were made.

RESULTS

2736/6225(44%) of patients read notes; among these, 1 in 12 patients used the tool, submitting 260 reports. Nearly all (96%) respondents reported understanding the note. Patients and care partners documented potential safety concerns in 23% of reports; 2% did not understand the care plan and 21% reported possible mistakes, including medications, existing health problems, something important missing from the note or current symptoms. Among these, 64% were definite or possible safety concerns on clinician review, and 57% of cases confirmed with patients resulted in a change to the record or care. The feedback tool exceeded the reporting rate of our ambulatory online clinician adverse event reporting system several-fold. After a year, 99% of patients and care partners found the tool valuable, 97% wanted it to continue, 98% reported unchanged or improved relationships with their clinician, and none of the providers in the small pilot reported worsening workflow or relationships with patients.

CONCLUSIONS

Patients and care partners reported potential safety concerns in about one-quarter of reports, often resulting in a change to the record or care. Early data from an OpenNotes patient reporting tool may help engage patients as safety partners without apparent negative consequences for clinician workflow or patient-clinician relationships.

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.

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm

Background

Estimates suggest that, in NHS hospitals, incidents causing harm to patients occur in 10% of admissions, with costs to the NHS of > £2B. About one-third of harmful events are believed to be preventable. Strategies to reduce patient safety incidents (PSIs) have mostly focused on changing systems of care and professional behaviour, with the role that patients can play in enhancing the safety of care being relatively unexplored. However, although the role and effectiveness of patient involvement in safety initiatives is unclear, previous work has identified a general willingness among patients to contribute to initiatives to improve health-care safety.

Aim

Our aim in this programme was to design, develop and evaluate four innovative approaches to engage patients in preventing PSIs: assessing risk, reporting incidents, direct engagement in preventing harm and education and training.

Methods and results

We developed tools to report PSIs [patient incident reporting tool (PIRT)] and provide feedback on factors that might contribute to PSIs in the future [Patient Measure of Safety (PMOS)]. These were combined into a single instrument and evaluated in the Patient Reporting and Action for a Safe Environment (PRASE) intervention using a randomised design. Although take-up of the intervention by, and retention of, participating hospital wards was 100% and patient participation was high at 86%, compliance with the intervention, particularly the implementation of action plans, was poor. We found no significant effect of the intervention on outcomes at 6 or 12 months. The ThinkSAFE project involved the development and evaluation of an intervention to support patients to directly engage with health-care staff to enhance their safety through strategies such as checking their care and speaking up to staff if they had any concerns. The piloting of ThinkSAFE showed that the approach is feasible and acceptable to users and may have the potential to improve patient safety. We also developed a patient safety training programme for junior doctors based on patients who had experienced PSIs recounting their own stories. This approach was compared with traditional methods of patient safety teaching in a randomised controlled trial. The study showed that delivering patient safety training based on patient narratives is feasible and had an effect on emotional engagement and learning about communication. However, there was no effect on changing general attitudes to safety compared with the control.

Conclusion

This research programme has developed a number of novel interventions to engage patients in preventing PSIs and protecting them against unintended harm. In our evaluations of these interventions we have been unable to demonstrate any improvement in patient safety although this conclusion comes with a number of caveats, mainly about the difficulty of measuring patient safety outcomes. Reflecting this difficulty, one of our recommendations for future research is to develop reliable and valid measures to help efficiently evaluate safety improvement interventions. The programme found patients to be willing to codesign, coproduce and participate in initiatives to prevent PSIs and the approaches used were feasible and acceptable. These factors together with recent calls to strengthen the patient voice in health care could suggest that the tools and interventions from this programme would benefit from further development and evaluation.

Trial registration

Current Controlled Trials ISRCTN07689702.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

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.

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

This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

Blame the Patient, Blame the Doctor or Blame the System? A Meta-Synthesis of Qualitative Studies of Patient Safety in Primary Care

OBJECTIVE

Studies of patient safety in health care have traditionally focused on hospital medicine. However, recent years have seen more research located in primary care settings which have different features compared to secondary care. This study set out to synthesize published qualitative research concerning patient safety in primary care in order to build a conceptual model.

METHOD

Meta-ethnography, an interpretive synthesis method whereby third order interpretations are produced that best describe the groups of findings contained in the reports of primary studies.

RESULTS

Forty-eight studies were included as 5 discrete subsets where the findings were translated into one another: patients' perspectives of safety, staff perspectives of safety, medication safety, systems or organisational issues and the primary/secondary care interface. The studies were focused predominantly on issues seen to either improve or compromise patient safety. These issues related to the characteristics or behaviour of patients, staff or clinical systems and interactions between staff, patients and staff, or people and systems. Electronic health records, protocols and guidelines could be seen to both degrade and improve patient safety in different circumstances. A conceptual reading of the studies pointed to patient safety as a subjective feeling or judgement grounded in moral views and with potentially hidden psychological consequences affecting care processes and relationships. The main threats to safety appeared to derive from 'grand' systems issues, for example involving service accessibility, resources or working hours which may not be amenable to effective intervention by individual practices or health workers, especially in the context of a public health system.

CONCLUSION

Overall, the findings underline the human elements in patient safety primary health care. The key to patient safety lies in effective face-to-face communication between patients and health care staff or between the different staff involved in the care of an individual patient. Electronic systems can compromise safety when they override the opportunities for face-to-face communication. The circumstances under which guidelines or protocols are seen to either compromise or improve patient safety needs further investigation.

Developing person-centred analysis of harm in a paediatric hospital: a quality improvement report

The provision of safe care is complex and difficult to achieve. Awareness of what happens in real time is one of the ways to develop a safe system within a culture of safety. At Great Ormond Street Hospital, we developed and tested a tool specifically designed for patients and families to report harm, with the aim of raising awareness and opportunities for staff to continually improve and provide safe care. Over a 10-month period, we developed processes to report harm. We used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. We measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting. Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities. Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified 'near-misses' and 'critical incidents' by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. We believe that this will lead to improved and safer care in the longer term.

Involving patients in understanding hospital infection control using visual methods

AIMS AND OBJECTIVES

This paper explores patients' perspectives on infection prevention and control.

BACKGROUND

Healthcare-associated infections are the most frequent adverse event experienced by patients. Reduction strategies have predominantly addressed front-line clinicians' practices; patients' roles have been less explored.

DESIGN

Video-reflexive ethnography.

METHODS

Fieldwork undertaken at a large metropolitan hospital in Australia involved 300 hours of ethnographic observations, including 11 hours of video footage. This paper focuses on eight occasions, where video footage was shown back to patients in one-on-one reflexive sessions.

FINDINGS

Viewing and discussing video footage of clinical care enabled patients to become articulate about infection risks, and to identify their own roles in reducing transmission. Barriers to detailed understandings of preventative practices and their roles included lack of conversation between patients and clinicians about infection prevention and control, and being ignored or contradicted when challenging perceived suboptimal practice. It became evident that to compensate for clinicians' lack of engagement around infection control, participants had developed a range of strategies, of variable effectiveness, to protect themselves and others. Finally, the reflexive process engendered closer scrutiny and a more critical attitude to infection control that increased patients' sense of agency.

CONCLUSION

This study found that patients actively contribute to their own safety. Their success, however, depends on the quality of patient-provider relationships and conversations. Rather than treating patients as passive recipients of infection control practices, clinicians can support and engage with patients' contributions towards achieving safer care.

RELEVANCE TO CLINICAL PRACTICE

This study suggests that if clinicians seek to reduce infection rates, they must start to consider patients as active contributors to infection control. Clinicians can engage patients in conversations about practices and pay attention to patient feedback about infection risk. This will broaden clinicians' understandings of infection control risks and behaviours, and assist them to support appropriate patient self-care behaviour.

Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study

Introduction

Patient safety research has tended to focus on hospital settings, although most clinical encounters occur in primary care, and to emphasize practitioner errors, rather than patients' own understandings of safety.

Objective

To explore patients' understandings of safety in primary care.

Methods

Qualitative interviews were conducted with patients recruited from general practices in northwest England. Participants were asked basic socio‐demographic information; thereafter, topics were largely introduced by interviewees themselves. Transcripts were coded and analysed using NVivo10 (qualitative data software), following a process of constant comparison.

Results

Thirty‐eight people (14 men, 24 women) from 19 general practices in rural, small town and city locations were interviewed. Many of their concerns (about access, length of consultation, relationship continuity) have been discussed in terms of quality, but, in the interviews, were raised as matters of safety. Three broad themes were identified: (i) trust and psycho‐social aspects of professional–patient relationships; (ii) choice, continuity, access, and the temporal underpinnings of safety; and (iii) organizational and systems‐level tensions constraining safety.

Discussion

Conceptualizations of safety included common reliance on a bureaucratic framework of accreditation, accountability, procedural rules and regulation, but were also individual and context‐dependent. For patients, safety is not just a property of systems, but personal and contingent and is realized in the interaction between doctor and patient. However, it is the systems approach that has dominated safety thinking, and patients' individualistic and relational conceptualizations are poorly accommodated within current service organization.

Patients' Perspectives of Surgical Safety: Do They Feel Safe?

BACKGROUND

Increased focus on reducing patient harm has led to surgical safety initiatives, including time-out, surgical safety checklists, and debriefings. The perception of the lay public of the surgical safety process is largely unknown.

METHODS

A 20-question survey focused on perceptions of surgical safety practice was distributed to a random sample of patients following elective operations requiring hospitalization. Responses were measured by a 7-point Likert scale. Qualitative feedback was obtained through nonphysician-moderated sessions. Participation was voluntary and anonymous.

RESULTS

Surveys were distributed to 345 patients of whom 102 (29.5%) responded. Overall, patients felt safe as evidenced by scores for the questions "I felt safe the day of my surgery" (6.53 ± 0.72) and "Mistakes rarely happen during surgery" (5.39 ± 1.51). Patients undergoing their first surgery and patients with higher income levels were associated with a significant decrease in specific safety perceptions. Qualitative feedback sessions identified the physician-patient relationship as the most important factor positively influencing patient safety perceptions.

CONCLUSION

Current surgical safety practice is perceived positively by our patients; however, patients still identify physician-patient interactions, relationships, and trust as the most positive factors influencing their perception of the safety environment.

Implementation of patient safety and patient-centeredness strategies in Iranian hospitals

OBJECTIVE

To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran.

METHODS

A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009-2010.

RESULTS

The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient's diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals.

CONCLUSIONS

Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.

The WHO surgical safety checklist: survey of patients' views

BACKGROUND

Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study was to assess patients' views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in.

METHOD

Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients' views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire.

RESULTS

141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly.

CONCLUSIONS

It is feasible and instructive to capture patients' views of the delivery of safety improvements like the checklist. We have demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use.

Quality and safety issues highlighted by patients in the handling of laboratory test results by general practices--a qualitative study

Background

In general practice internationally, many care teams handle large numbers of laboratory test results relating to patients in their care. Related research about safety issues is limited with most of the focus on this workload from secondary care and in North American settings. Little has been published in relation to primary health care in the UK and wider Europe. This study aimed to explore experiences and perceptions of patients with regards to the handling of test results by general practices.

Methods

A qualitative research approach was used with patients. The setting was west of Scotland general practices from one National Health Service territorial board area. Patients were purposively sampled from practice held lists of patients who received a number of laboratory tests because of chronic medical problems or surveillance of high risk medicines. Focus groups were held and were audio-recorded. Tapes were transcribed and subjected to qualitative analysis. Transcripts were coded and codes merged into themes by two of the researchers.

Results

19 participants from four medical practices took part in four focus groups. The main themes identified were: 1. Patients lacked awareness of the results handling process in their practice. 2. Patients usually did not contact their practice for test results, unless they considered themselves to be ill. 3. Patients were concerned about the appropriateness of administrators being involved in results handling. 4. Patients were concerned about breaches of confidentiality when administrators were involved in results handling. 5. Patients valued the use of dedicated results handling staff. 6. Patients welcomed the use of technology to alert them to results being available, and valued the ability to choose how this happened.

Conclusions

The study confirms the quality and safety of care problems associated with results handling systems and adds to our knowledge of the issues that impact in these areas. Practices need to be aware that patients may not contact them about results, and they need to publicise their results handling processes to patients and take steps to reassure patients about confidentiality with regards to administrators.