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Learning from patient and family experiences of unsafe care��Dr Tom Reader

Presented to: Clinical Human Factors Group, 19/10/21

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"Complaints were not given a high enough priority in identifying issues and learning lessons” …yet… "the truth (of unsafe care) was uncovered... mainly because of the persistent complaints made by a very determined group of patients and those close to them" (Francis, 2013, p. 7 & 65)

_____________________________________________________________________________________________________________________________________________ Vincent, C. A., & Coulter, A. (2002). Patient safety: what about the patient?. BMJ Quality & Safety, 11(1), 76-80.

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: The Stationery Office

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What is the role of patients in patient safety?

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_____________________________________________________________________________________________________________________________________________ Davis, R. E., Jacklin, R., Sevdalis, N., & Vincent, C. A. (2007). Patient involvement in patient safety: what factors influence patient participation and engagement?. Health expectations, 10(3), 259-267.

Lyons, M. (2007). Should patients have a role in patient safety? A safety engineering view. BMJ Quality & Safety, 16(2), 140-142.

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Patients are already involved

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_____________________________________________________________________________________________________________________________________________ Reader, T. W., Gillespie, A., & Roberts, J. (2014). Patient complaints in healthcare systems: a systematic review and coding taxonomy. BMJ quality & safety, 23(8), 678-689.

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Complaints to the NHS in 2017-18

  • Written letters of complaint submitted after a “threshold” of dissatisfaction has been crossed

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  • Unsolicited, unstructured, and sent by patients or family members; a moment of engagement with healthcare institutions

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  • Distilled data: some of the worst experiences within the 243 million NHS visits that occur per year

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  • Institutions respond to individual complaints, and are evaluated on the number of complaints received

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Three studies

Study 1: Analysis of 1,100 healthcare complaints from 56 NHS trusts – using the Healthcare Complaints Analysis Tool – to determine the types of safety insights provided by patients and families (HCAT codifies complaints in terms of the severity of safety problems reported)

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Study 2: Comparison of 5 years of complaints (n=5,265) and staff incident reports (n=81,077) at a large multisite hospital to examine overlaps in reporting and content

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Study 3: Analysis of 2,017 healthcare complaints from 59 NHS trusts using HCAT to assess the validity of safety information provided by patients and families

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Study 1. Patients observe “blind spots” in care

- 32% of complaints related to problems in accessing care (emergency) or discharge (e.g., no instructions)

- 54% of complaints relate to systemic problems (e.g., across multiple units, recurring problems relating to neglect)

- 35% of complaints relate to problems in omissions (e.g., not receiving medications, treatment plans)

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_____________________________________________________________________________________________________________________________________________ Gillespie, A., & Reader, T. W. (2018). Patient‐centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety. The Milbank Quarterly, 96(3), 530-567

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Blindspots: Systemicness

Complaints can reveal systematic failings in care that cross multiple stages, problems, staff groups, and visits: these are the most severe

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Study 2. Patient and staff accounts of error can differ

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_____________________________________________________________________________________________________________________________________________ Van Dael, J., Gillespie, A., Reader, T., Smalley, K., Papadimitriou, D., Glampson, B., ... & Mayer, E. (2021). Getting the whole story: Integrating patient complaints and staff reports of unsafe care. Journal of Health Services Research & Policy, 13558196211029323.

Clinical omissions �

“they forgot to administer my medication”; “I was discharged without examination”

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Failure to listen

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“my symptoms were dismissed”;

“his screams of pain were ignored”;

“no one believed me”

Internal coordination �

“blood transfusion error”;

“test not received in the lab”;

“sample gone missing”

74% of incidents reported by patients as moderate or higher harm (eg, “kidney failure”; “organ perforation”) were reported by staff as low or no harm; patients take a longer view on harm

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Study 3. Healthcare complaints about safety problems have validity

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_____________________________________________________________________________________________________________________________________________ Reader, T. W., & Gillespie, A. (2021). Stakeholders in safety: Patient reports on unsafe clinical behaviors distinguish hospital mortality rates. Journal of Applied Psychology, 106(3), 439.

Low severity

Medium severity

High severity

Health-care assistant unable to find vein for blood sample (id_635)

Nurse did not have experience for providing surgical aftercare (id_225)

Locum doctor operated instead of a gallbladder surgeon (id_613)

Hour delay in replacing catheter after it had been incorrectly put in (id_1069)

Doctor refused to administer more pain relief because he was too busy (id_1407)

Heavily bleeding patient in labor left in corridor for 4–5 hours (id_2089)

Blood test causing a large hematoma (id_815)

Knee operation resulting in nerve damage (id_919)

Repair of aortic graft resulting in catastrophic infections (id_1099)

Dirty pajamas not changed (id_397)

Patient in poor hygienic state (e.g., no cleaning, shaving) (id_2090)

Patient lying in own urine and bed sores for 10 days (id_1727)

Short delay in administration of antibiotics (id_1677)

Patient given steroid injections instead of anesthetic injections (id_1482)

Did not stop administering Epilim to young patient, resulting in pancreatitis and diabetes (id_360)

Fractured wrist misdiagnosed as muscle damage; revised a week later (id_518)

Severe pneumonia and sepsis misdiagnosed as slight (nonurgent) infection (id_72)

Tumor in kidney misdiagnosed as cyst before donation of the other kidney (id_413)

  • Severity of problems reported in healthcare complaints significantly predicts hospital mortality (R2 of 0.169)
  • Staff incident reports do not predict mortality

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_____________________________________________________________________________________________________________________________________________ Gillespie, A., & Reader, T. W. (2021). Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment. BMJ quality & safety, 30(6), 484-492.

  • Patient and family letters of complaint identify safe and high-quality healthcare

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  • Generally not analysed by hospitals

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  • Also a source of learning

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  • Analysis of 1267 compliments

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Conclusions

  • Patients and families frequently report experiences of unsafe care to hospitals: whilst the data is unstructured and unsolicited, it is sent to help hospitals learn and improve safety management

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  • The value of patient and family reports on unsafe care are that they i) identify blind spots in service provision, ii) augment analyses of why adverse events occur, and iii) have validity in terms of patient safety metrics

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  • Learning from patient experiences of unsafe care remains a challenge: institutions are unsure how to analyse or use these data. Yet, complaints and other narrative data (e.g., online reviews) can capture the most serious and pertinent safety problems experienced by patients.

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