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Bryant J, Carey M, Sanson-Fisher R, et al. J Patient Saf. 2021;17(5):e387-e392.
When an error or adverse event occurs, patients and families want to be informed. In this study of oncology patients, more than one quarter perceived an adverse event had occurred. While most were informed soon after the event occurred and given an explanation, fewer than half were given information on how to move forward with a complaint if they wished. Regular communication between patients and providers about actual or perceived adverse events may decrease the risk of it happening again.
Claydon O, Keeler B, Khanna A. Int J Qual Health Care. 2021;33(3).
Patient complaints may provide insight into patient safety. Three hundred and ninety-nine patient or family complaints against the surgery departments at one United Kingdom hospital were examined. A quarter of those complaints related to communication with hospital staff, 24% were related to out-of-hospital delays, and 22% were clinical issues. Interventions aimed at improving communication with patients and families may improve patient experiences.
van Dael J, Gillespie A, Reader TW, et al. J Health Serv Res Policy. 2021;Epub Jul 7.
This retrospective study linked patient complaint data with staff incident reports to better understand the causes and severity of patient harm. Staff reported incidents with linked patient complaints frequently described greater harm from the safety incident and often noted adjacent safety events not reported by staff. The researchers explored linked events that generated contested patient and staff accounts, and how differing interpretations of the same incidents can support organizational learning.

ImproveDx. July 2021;8(4).

Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This article describes existing efforts to examine diagnostic error through reporting and highlights tactics being employed.
Synan LT, Eid MA, Lamb CR, et al. Surgery. 2021;Epub May 25.
This study compared unsolicited hospital reviews posted online by patients with Hospital Compare patient satisfaction and postsurgical safety indicators. While there was variation in consumer ratings between platforms, unstructured consumer reviews were generally correlated with Hospital Compare patient satisfaction scores; consumer platforms were not consistently correlated with postsurgical patient safety indicators.
Groves PS, Bunch JL, Cannava KE, et al. Nurs Res. 2021;70(2):106-113.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. This qualitative study explored bedside nurses' experience responding to safety concerns expressed by patients or their families. Safety interventions designed to be used by nurses should be developed with nurses’ routine safety work in mind, be sensitive to the vulnerability of patients, and respect patient and family input.
Giardina TD, Korukonda S, Shahid U, et al. BMJ Qual Saf. 2021;Epub Feb 19.
Patient complaints are increasingly used to identify opportunities for patient safety improvement and to predict avoidable patient harm. In this retrospective study, researchers analyzed patient complaint and medical record data and found that manual reviews by clinicians can identify patterns of failures in the diagnostic process. Qualitative analysis of complaints revealed three themes associated with diagnostic error – reports of return visits for the same or worsening symptoms, interpersonal issues, and diagnostic testing issues.

Boodman SG. Washington Post. February 20, 2021.

Difficult diagnostic journeys are compounded by lack of clinician empathy, bias awareness, and critical thinking. This piece shares the story of a patient whose efforts to identify the cause of her pain were hampered by heuristics, premature closure, and poor patient relationship building.

Sorry Works! 

Patients and families experiencing medical error may not always have access to the support needed to navigate the system to inform improvements and receive appropriate restitution. This hotline will provide general information to individuals that contact the organization for help when they feel an error may have occurred in their care or the care of a family member. 
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28(4):685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Sundwall DN, Munger MA, Tak CR, et al. Health Equity. 2020;4(1):430-437.
This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.  

Heath S. Patient Engagement HIT. October 29, 2020.

Twitter is evolving as a useful data source for patient safety. This news story discusses an examination of public use of a patient-complaint hashtag that recorded patient experiences of misdiagnosis, disrespect and miscommunication that contributed to poor relations with physicians, medical errors, and harm.
Kok J, Wallenburg I, Leistikow I, et al. Safety Sci. 2020;131:104914.
Measuring errors and adverse events in health care remains challenging, but is essential to achieving safe care. Using qualitative research and informal data, the authors discuss the importance of “soft signals” in patient safety risk assessment, which are warning signs that are not typically formally measured but that indicate problems with safe care, such as patient complaints about poor hygiene, observed disruptive staff behavior, and whistleblower complaints.
Obadan-Udoh E, Panwar S, Yansane A-I, et al. J Evid Based Dent Pract. 2020;20(3):101424.
Patient safety events are common in dentistry. A survey administered to adult dental patients found that a majority of them were concerned about their safety at the dental office but that those concerns were not routinely shared with dental providers or clinic staff. Efforts to improve patient engagement and speaking up behaviors can improve safety in dentistry.
Canadian Patient Safety Institute;
Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.
Alsabri M, Boudi Z, Zoubeidi T, et al. J Patient Saf. 2020;Epub Aug 28.
In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.

London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23(3):549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
Bontempo AC, Mikesell L. Diagnosis (Berl). 2020;7(2):97-106.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. In this study of 758 patients with endometriosis, three-quarters reported being misdiagnosed with another physical and/or mental health problem, most commonly by their gynecologist or general practitioner.
Hernan AL, Giles SJ, Beks H, et al. BMJ Open. 2020;10(6):e037887.
This feasibility study surveyed 1,750 patients using the primary care patient measure of safety (PC PMOS) tool to obtain patient feedback about the safety of their care in primary care settings. Findings indicate that this approach complements existing safety improvement activities, can be integrated into existing feedback service requirements, and should be explored further by larger effectiveness trials.