Putting a Face on Medical Errors: A Patient Perspective

Kooienga, Sarah; Stewart, Valerie T.

doi:10.1111/j.1945-1474.2010.00121.x

Cited by 12 publications

(22 citation statements)

References 17 publications

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“…9 A 2015 literature review showed disclosure to be a significant topic of debate. 8 The few primary research studies of patient experiences of open disclosure processes 9,[11][12][13][14] have consistently found that open disclosure did not meet patient expectations. In Australia, the 100 Patient Stories project found that although patients welcomed open disclosure, they were not adequately followed-up with tangible support or information about changes in practice, were not being offered an apology and were not being given the opportunity to meet with staff directly involved in the event.…”

Section: Introductionmentioning

confidence: 99%

Disclosure of adverse events: a data linkage study reporting patient experiences among Australian adults aged ≥45 years

Walton

Harrison

Smith‐Merry

et al. 2019

Aust. Health Review

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Since Australia initiated national open disclosure standards in 2002, open disclosure policies have been adopted in all Australian states and territories. Yet, research evidence regarding their adoption is limited. The aim of the present study was to determine the frequency with which patients who report an adverse event had information disclosed to them about the incident, including whether they participated in a formal open disclosure process, their experiences of the process and the extent to which these align with the current New South Wales (NSW) policy. A cross-sectional survey about patient experiences of disclosure associated with an adverse event was administered to a random sample of 20000 participants in the 45 and Up Study who were hospitalised in NSW, Australia, between January and June 2014. Of the 18993 eligible potential participants, completed surveys were obtained from 7661 (40% response rate), with 474 (7%) patients reporting an adverse event. Of those who reported an adverse event, a significant majority reported an informal or bedside disclosure (91%; 430/474). Only 79 patients (17%) participated in a formal open disclosure meeting. Most informal disclosures were provided by nurses, with only 25% provided by medical practitioners. Experiences of open disclosure may be enhanced by informing patients of their right to full disclosure in advance of or upon admission to hospital, and recognition of and support for informal or bedside disclosure for appropriate types of incidents. A review of the open disclosure guidelines in relation to the types of adverse events that require formal open disclosure and those more suitable to informal bedside disclosure is indicated. Guidelines for bedside disclosure should be drafted to assist medical practitioners and other health professionals facilitate and improve their communications about adverse events. Alignment of formal disclosure with policy requirements may also be enhanced by training multidisciplinary teams in the process. While open disclosure is required in all cases of serious adverse events, patients' experiences are variable, and lack of, or poor quality disclosures are all too common. This paper presents experiences reported by patients across New South Wales in a large cross-sectional survey. Unlike previous studies of open disclosure, recently hospitalised patients were identified and invited using data linkage with medical records. Findings suggest that most patients receive informal disclosures rather than a process that aligns with the current policy guidance. Experiences of open disclosure may be enhanced by informing patients of their right to full disclosure in advance of or upon admission to hospital, and recognition of and support for informal or bedside disclosure for appropriate types of incidents.

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Section: Introductionmentioning

confidence: 99%

Disclosure of adverse events: a data linkage study reporting patient experiences among Australian adults aged ≥45 years

Walton

Harrison

Smith‐Merry

et al. 2019

Aust. Health Review

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show abstract

“…One study which explored how patients had experienced disclosure and error described patients reporting that the actual error was less concerning than the continued relationship with their health-care provider. 84 These individuals described being treated not as experts in their own experience of care, but as outsiders. The authors described this as patients feeling like a foreigner in a strange land experiencing a different culture and language, and highlight how poor communication suggests a conflict between a model of person-centred care, with the patient-provider relationship at its heart, and the business or corporate model of health care.…”

Section: Recognising Patient and Caregiver Expectationsmentioning

confidence: 99%

“…A number of individuals highlight the role that patients and families may have. 84 Patients and their families often have a unique perspective on their experiences and can provide information and insights that health-care providers and systems administrators may not appreciate or know. 108 Allowing patients and families to engage in a dialogue as part of disclosure allows them to describe what may be important insights into factors leading up to and following health-care incidents, and emotional harms that occur when these incidents are inadequately communicated or responded to, and to make a potential contribution to patient safety.…”

Section: Learning From Mistakes and Errormentioning

confidence: 99%

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

Birks

Harrison

Bosanquet

et al. 2014

Health Services and Delivery Research

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BackgroundIn 2009 the UK National Patient Safety Agency relaunched its Being Open framework to facilitate the open disclosure of adverse events to patients in the NHS. The implementation of the framework has been, and remains, challenging in practice.AimThe aim of this work was to both critically evaluate and extend the current evidence base relating to open disclosure, with a view to supporting the implementation of a policy of open disclosure of adverse events in the NHS.MethodsThis work was conducted in three phases. The first phase comprised two focused systematic literature reviews, one summarising empirical research on the effectiveness of interventions to enhance open disclosure, and a second, broader scoping review, looking at reports of current opinion and practice and wider knowledge. The second phase involved primary qualitative research with the objective of generating new knowledge about UK-based stakeholders’ views on their role in and experiences of open disclosure. Stakeholder interviews were analysed using the framework approach. The third phase synthesised the findings from the first two phases to inform and develop a set of short pragmatic suggestions for NHS trust management, to facilitate the implementation and evaluation of open disclosure.ResultsA total of 610 papers met the inclusion criteria for the broad review. A large body of literature discussed open disclosure from a number of related, but sometimes conflicted, perspectives. Evidential gaps persist and current practice is based largely on expert consensus rather than evidence. There appears to be a tension between the existing pragmatic guidance and the more in-depth critiques of what being consistent and transparent in health care really means. Eleven papers met the inclusion criteria for the more focused review. There was little evidence for the effectiveness of disclosure alone on organisational or individual outcomes or of interventions to promote and support open disclosure. Interviews with stakeholders identified strong support for the basic principle of being honest with patients or relatives when someone was seriously harmed by health care. In practice however, the issues are complex and there is confusion about a number of issues relating to disclosure policies in the UK. The interviews generated insights into the difficulties perceived within health care at individual and institutional levels, in relation to fully implementing the Being Open guidance.ConclusionsThere are several clear strategies that the NHS could learn from to implement and sustain a policy of openness. Literature reviews and stakeholder accounts both identified the potential benefits of a culture that was generally more open (not just retrospectively open about serious harm). Future work could usefully evaluate the impact of disclosure on legal challenges within the NHS, best practice in models of support and training for open disclosure, embedding disclosure conversations in critical incident analysis and disclosure of less serious events.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Ensuring quality health care and positive health outcomes for patients is a priority for health care providers (ANA, 2001(ANA, , 2010CNA, 2008;CNO, 2002). However, researchers suggest that definitions and measurements of quality health care developed from the perspective of patients are lacking (Brown, 2007;Kooienga & Stewart, 2011;Wong, Watson, Young, & Regan, 2008). A qualitative thematic content analysis of telephone interviews with 30 patients was conducted as part of a larger randomized, experimental design, mixed methods study to explore patients' perspectives on quality health care and the meaning of health care error (Kooienga & Stewart, 2011).…”

Section: Qowl Predictors and Patient Outcomesmentioning

confidence: 99%

“…However, researchers suggest that definitions and measurements of quality health care developed from the perspective of patients are lacking (Brown, 2007;Kooienga & Stewart, 2011;Wong, Watson, Young, & Regan, 2008). A qualitative thematic content analysis of telephone interviews with 30 patients was conducted as part of a larger randomized, experimental design, mixed methods study to explore patients' perspectives on quality health care and the meaning of health care error (Kooienga & Stewart, 2011). Patients reported that health care errors were associated with lack of communication and poor communication skills among health care providers (Kooienga & Stewart, 2011).…”

Section: Qowl Predictors and Patient Outcomesmentioning

confidence: 99%

Evaluating and Improving Nurses' Health and Quality of Work Life

2013

Workplace Health Saf

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health and well-being of others, choice, dignity, confidentiality, accountability, and quality practice environments are values defined within nursing associations' codes of ethics (American Nurses Association [ANA], 2001; Canadian Nurses Association [CNA], 2008). Nurses have an advocacy role in promoting quality practice environments that ensure safe, competent care congruent with nursing's professional and ethical standards of practice for the health and well-being of all clients (ANA, 2001, 2010; CNA, 2008; College of Nurses of Ontario [CNO], 2002). Similarly, occupational health nurses are the largest professional group providing care to workers (American Association of Occupational Health Nurses, Inc. [AAOHN], n.d.) and practice in accordance with legal and ethical professional standards (AAOHN, n.d.; Rogers, 2012). Occupational health nurses work in a variety of settings and have a pivotal role in evaluating nurses' quality of work life (QOWL); nurses' QOWL protects the health of nurses, enabling them to provide safe, quality health care resulting in positive client health outcomes (Rogers, 2012). Key terms related to the discussion of nurses' QOWL are presented in the Sidebar.

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Putting a Face on Medical Errors: A Patient Perspective

Cited by 12 publications

References 17 publications

Disclosure of adverse events: a data linkage study reporting patient experiences among Australian adults aged ≥45 years

Disclosure of adverse events: a data linkage study reporting patient experiences among Australian adults aged ≥45 years

An exploration of the implementation of open disclosure of adverse events in the UK: a scoping review and qualitative exploration

Evaluating and Improving Nurses' Health and Quality of Work Life

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