Search results for "Hospitals"

Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety concerns to the attention of health care systems. Only 37 errors were reported during the study period of 17 months; most reports did not involve patient harm. As with prior studies of patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes reported was problems with diagnosis or advice from a provider. These results demonstrate the feasibility of implementing an incident reporting system for patients and families, and they underscore the need to focus on diagnostic safety in outpatient settings. A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care.

Prior studies have demonstrated that patients and families can report adverse events that would not otherwise have been detected. This qualitative study explored perceptions of adolescent patients and their parents about adverse event reporting. Positive perceptions of care led to participants being more willing to report an adverse event; whereas, if they felt the quality of care was poor, they would be less likely to report. In addition, families who perceived providers as good communicators were more comfortable with reporting adverse events. Families were interested in multiple modes of reporting including face-to-face meetings, internet-based reporting, live telephone calls, paper mail, and smartphone-enabled reporting of adverse events.

Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.

This review explored the evidence to identify seven themes that contribute to patients feeling unsafe, including loss of control, poor communication, and lack of clinical staff engagement. The authors discuss how these concerns go beyond mistakes being made and relate more broadly to an overall perception of poor quality.

Patient complaints can provide insights about patient safety problems. This qualitative analysis examined positive and negative feedback submitted by patients. Investigators found that most complaints related more to interpersonal factors than clinical processes and the majority of positive feedback expressed gratitude, consistent with prior studies.

The role of patients in promoting their own safety remains controversial. Although some studies have shown that patients are able to identify errors not detected via other means, others have shown that patients may conflate service quality with safety issues. In this feasibility study, authors describe the development and testing of an intervention designed to collect feedback from hospitalized patients about the safety of their care.

Patients' perceptions of care may provide valuable insights for improving safety. Researchers surveyed patients seen in an academic emergency department over a one-year period. They found that patients were able to accurately identify adverse events and near misses, only a small fraction of which were also submitted to an existing incident reporting system.

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.

Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.

Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.

Rapid response teams (RRTs) are a widely implemented safety intervention with a growing body of literature supporting their effectiveness. At some hospitals, families can activate the RRT if they are concerned. This systematic review identified successful implementation strategies for family-activated RRTs, but researchers found no clear evidence that this approach improves patient outcomes.

Patient safety hotlines are a strategy to improve reporting and collecting of comments from patients, clinicians, and staff to notify hospitals about problems in care processes. This report describes the development of one such program, the Health Care Safety Hotline. Drawing from design and testing of the hotline, the authors conclude that more research is needed to understand why patients were more likely to access reports than contribute to them and how to simplify goals for the tool to enhance its usefulness.

This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.

This study applied a patient complaint taxonomy to complaints reported over a 5-year period to a large organization in Australia. Researchers were able to assign each of the complaints to one of the domains of the original taxonomy, but they discovered potential refinements to the model that may improve widespread applicability.

Patient perspectives are critical to inform patient safety efforts. This systematic review identified studies of patient experiences with adverse events. Included studies demonstrate that the types of adverse events patients most often identify are medication errors and suboptimal communication, and that patient demographic characteristics influence the likelihood of reporting these events. Calling for increased use of patient experiences in future studies, the authors suggest that investigations into adverse events are incomplete if patient perspectives are not included. These results demonstrate the ongoing need to enhance patient engagement in safety research. A previous AHRQ WebM&M perspective delves further into engaging patients in safety improvement.

This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.

This interview study found that patients express varying levels of comfort with raising safety concerns to health care staff. The authors recommend increasing patient engagement through partnership rather than by encouraging patients to challenge health care teams.

Patient and family stories of harm are increasingly promoted as a strategy to provide insights into medical errors. This radio segment interviews a patient advocate whose daughter died due to medical errors, including failure-to-rescue and a health care–associated infection, and who speaks about that experience to educate clinicians on the importance of patient safety and listening to patients' families.

Complaints are a proactive way to monitor and address recurring problems that may result in adverse events and system failures. This report discusses progress achieved through complaint response efforts in the United Kingdom and provides recommendations to augment how complaints are managed to develop further improvements.

In this observational study, reports of poor patient experience was correlated with higher incidence of patient harm determined from medical record review. These findings are consistent with a recent systematic review which found that patient experience was associated with a variety of patient safety and quality outcomes.