Patients may define medical errors differently than you
Make it easy for patients to report safety concerns
If a nurse failed to respond to a patient's call light in a timely manner with no harm resulting, would you consider this a "medical error?" Probably not, but the patient might.
Hospital patients define medical errors much more broadly than the traditional clinical definitions of medical errors, says a new study of more than 1,600 patients at 12 Midwestern hospitals. For example, patients believe that errors include communication problems, lack of responsiveness, and falls.
The study shows the importance of explaining exactly what is meant by the term "medical error" if patients are to be effectively engaged in programs to prevent them, say the researchers. They recommend tailoring educational programs to address the fears and concerns of each patient, so patients can play a more active role in error prevention.
The study also found that error-related concerns alone, even if not linked to an actual error, are enough to significantly affect a patient's perception of their entire experience.
There is no question that patient satisfaction is an important element in the overall determination of quality, says Patti Muller-Smith, RN, EdD, CPHQ, a Shawnee, OK-based consultant working with hospitals on performance improvement and regulatory compliance. However, it's a mistake to expand the definition of a reportable incident to include the patient's perception, she cautions.
"This has the potential to compromise data reporting," says Muller-Smith. "It may also cloud the focus on making changes that will affect patient safety and improve patient medical outcomes."
Patient perspectives are so variable that the data cannot be considered valid from a statistical standpoint, Muller-Smith explains. "That is not to infer that it is not important. But quality professionals may lose focus if the scope of data gathered has perception and not factual data," she says.
Most patient satisfaction surveys and questionnaires already address the patient's perception of responsiveness to their needs. The issue you must consider is whether there is effective communication among caregivers that would impact a patient's overall sense of satisfaction with the care they received, says Muller-Smith.
"Many patients are frightened when they enter a hospital or have to seek care in an emergency department," she says. "There is a low level of trust in the health care system as a whole. A lot of media attention has been given to dramatic medical errors that have occurred, which continues to feed this distrust."
Although medical errors do occur, the media has blown things out of proportion with sensational headlines, says Patrice Spath, RHIT, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates. "Every day, thousands of patients are cared for in hospitals and very few of these patients experience a true medical error," says Spath.
But because of media coverage of catastrophic medical mistakes, many patients and their family members come in expecting errors to occur — thus, any deviation of what they consider to be the norm is thought to be an error. "We need to know if our patients feel unsafe and the reason behind these feelings. Then hospitals can educate patients on what to expect during their stay," says Spath.
Hospitals can use their existing customer satisfaction and feedback mechanisms to find out if patients feel unsafe and why, says Spath. For instance, some hospitals have added individuals from the community to hospital patient safety groups so that the voice of the consumer can be heard. "Health care is very complex. We need to make sure our patients feel safe during what can be a confusing and frightening experience," says Spath. "We must understand what makes them feel unsafe and address those concerns. Then hospitals can design strategies that address the root cause of these fears."
What is a medical error?
Quality professionals agree that there is little to be accomplished from attempting to clarify what constitutes a "medical error" with patients. "I doubt if we'll be able to educate patients as to the meaning of 'medical error.' We can't even seem to agree on the meaning!" says Spath.
What patients view as an "error" may actually be a miscommunication, inadequate pain control or failure to improve as quickly as they thought they would, and these things are not typically reportable incidents, says Spath.
Trying to correct what patients perceive as a medical error would be difficult at best, if not impossible, until public trust in the health care system is restored, says Muller-Smith. Restoring trust most likely will come from reducing actual medical errors and providing patients with more frequent information about what is being done for them, she says.
The study found that patients who received care in small and rural hospitals reported the fewest types of concerns, regardless of the severity of illness. "It is interesting to note that there is less concern about medical errors in hospitals where the patient is much more likely to know their caregivers better. They believe that they will receive good care because they know them," says Muller-Smith.
In large, busy, urban settings patients often have different caregivers each day so there is little time to form a relationship. Communication is probably the single most important aspect of reducing the patient's anxiety level, says Muller-Smith. "From a practical standpoint, this should be a major focus of making the patient feel safe and secure," she says.
Data from existing reportable incident criteria and patient satisfaction surveys should be used as indicators of overall quality, says Muller-Smith. "The goal is to provide an environment where the patient is safe and also feels safe," she says.
Analysis of sentinel events reported to The Joint Commission has demonstrated that communication leads to a variety of process failures that impact patient care, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC. For example, a patient about to undergo a radiology test with contrast has no awareness whether contrast will affect the patency of the peripherally inserted central catheter line — the patient just undergoes the experience of line insertion again.
Many attempts to understand the patient perspective are under way, including The Joint Commission's National Patient Safety Goal requiring encouragement of patients' active involvement in their own care as a patient safety strategy, and development of the Centers for Medicare & Medicaid Services HCAHPS survey instrument — the first national attempt to standardize patient satisfaction with care, in order to make "apples to apples" comparisons.
"Ask many questions, stay tuned to what patients are complaining about, and tie what you learn back into staff education," advises Swain. "When monitoring communication with patients, set your expectation to see staff using that information."
Consider implementing the following strategies to address patient perceptions about safety:
• Assess patient concerns about medical errors in real-time.
"You don't want to do this retrospectively. You want to be going around asking patients, 'Is there anything that has made you feel unsafe today?'" says Geri Amori, PhD, health care consultant with Shelburne, VT-based Risk Management and Patient Safety Institute. "That could be done by nurses, patient advocates or quality professionals. But there should be a place where it is reported daily."
• Give patients a simple way to report concerns.
There needs to be a quick and easy way for patients to report anything they believe is an error, says Amori.
Instead of educating patients about what is considered an "error," encourage them to tell you whenever they think an error has occurred and what they believe that error is, Amori advises. "We need to emphasize to patients that we want to know about anything they experience or see that they believe shouldn't have happened," she says. "If we create limitations about what we want reported, we could lose important information."
The patient's concern might not technically be considered an error, but might reveal communication or other patient safety issues that need to be addressed, Amori explains.
It is important that patients and family members have a mechanism for voicing immediate concerns, but this should not be done through the hospital's incident reporting system, says Spath. Instead, hospitals should make it very clear to patients and family members that any concern should be immediately brought to the attention of their caregiver.
"If the situation is not resolved to the patient or family member's satisfaction, they need to know how to contact the hospital's patient advocate or someone in a similar position," says Spath. For example, some hospitals encourage anxious patients or family members to call a special phone number to activate a rapid response team.
• Incorporate patient attitudes into safety programs.
Include these two questions on your patient satisfaction surveys, recommends Amori: Do you believe any errors occurred during your stay? What do you believe they were and may we contact you for more information?
Swain recommends these interventions, done by your hospital's guest relations department or senior management:
- Hold focus groups with parents of pediatric patients with stays exceeding four days, especially those coupled with an admission from the ED, since this group of patients was identified by researchers as having the most safety concerns. "Communication processes should be enhanced when talking to patients, since patients often feel they are 'talked over' or are being 'talked about,'" adds Swain.
- Train nurses in "scripting" to explain to patients why they are using patient safety techniques, such as patient identification, over and over at every patient encounter.
Patients may wrongly believe that the reason staff continually ask for their name is because they aren't communicating well. "If staff were proactive and said, 'It is important for your safety that we all double check who you are, so we will all be asking you your name and date of birth,' patients would expect this intervention and begin to participate, rather than think staff do not communicate," says Swain.
Similarly, since it takes about 20 seconds to use hand hygiene, during that time the staff could be telling the patient about the reason for cleaning their hands between patients and procedures. "That inclusion activity costs nothing, makes the patient part of the facility's safety program, and opens communication for patients to talk to staff about many related concerns," says Swain.
Reference
- Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf 2007; 33:5-14.
[For more information, contact:
Geri Amori, PhD, 105 Covington Lane, Shelburne, VT 05482. Phone: (802) 985-5458. Fax: (517) 327-4650. E-mail: [email protected].
Patti Muller-Smith, RN, EdD, CPHQ, Administrative Consulting Services, Box 3368, Shawnee, OK 74802. Phone: (405) 878-0118. E-mail: [email protected].
Patrice L. Spath, BA, RHIT, Health Care Quality Specialist, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: [email protected]. Web: www.brownspath.com.
Paula Swain, MSN, CPHQ, FNAHQ, Director of Clinical and Regulatory Review, Presbyterian Healthcare, 200 Hawthorne Lane, Charlotte, NC 28204. Phone: (704) 384-8856. E-mail: [email protected].]
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