Patients as partners in learning from unexpected events.

Adverse event investigation has not traditionally included patient perspectives. In this study, investigators interviewed patients and family members following an adverse event to determine whether they could identify any underlying causes of the incident. Each patient and family member was able to identify at least one contributing factor and make recommendations to address these underlying causes. The most frequent contributing cause reported was inadequate staff knowledge or qualification. However, the majority of participants were not involved in root cause analysis or other formal event investigation. This study is consistent with prior work that demonstrated the value of involving patients in error investigation. The authors conclude that patient perspectives should be included in event analysis.