What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents

Abstract

Purpose: Little is known about how well hospitalized patients can identify errors or injuries in their care. Accordingly, the purpose of this study was to elicit incident reports from hospital inpatients in order to identify and characterize adverse events and near‐miss errors. Subjects: We conducted a prospective cohort study of 228 adult inpatients on a medicine unit of a Boston teaching hospital. Methods: Investigators reviewed medical records and interviewed patients during the hospitalization and by telephone 10 days after discharge about “problems,”“mistakes,” and “injuries” that occurred. Physician investigators classified patients' reports. We calculated event rates and used multivariable Poisson regression models to examine the factors associated with patient‐reported events. Results: Of 264 eligible patients, 228 (86%) agreed to participate and completed 528 interviews. Seventeen patients (8%) experienced 20 adverse events; 1 was serious. Eight patients (4%) experienced 13 near misses; 5 were serious or life threatening. Eleven (55%) of 20 adverse events and 4 (31%) of 13 near misses were documented in the medical record, but none were found in the hospital incident reporting system. Patients with 3 or more drug allergies were more likely to report errors compared with patients without drug allergies (incidence rate ratio 4.7, 95% CI 1.7, 13.4). Conclusion: Inpatients can identify adverse events affecting their care. Many patient‐identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.

Key strategies to improve systems for managing patient complaints within health facilities – what can we learn from the existing literature?

“…individual interviewing of hospitalised patients or conducting follow-up by telephone on patient experiences of using health services) can be most effective in increasing the amount of patient feedback [37]. Other studies have also shown the effectiveness of actively solicited patient feedback [37,62]. …”

What Do Patients Think About Year-End Resident Continuity Clinic Handoffs?: A Qualitative Study

“…Additionally, the risks of these handoffs may be underestimated, since prior studies show that patients are often able to report adverse events that would be missed by chart review. 14,15 Furthermore, patients may be aware of the quality of inter-physician communication during care transitions and may give additional insights into methods to improve communication during clinic handoffs. 16 Therefore, to improve clinic handoffs, more insight into patient experiences and patient needs during this transition are crucial.…”

Mainstreaming Risk Management Education Into New Resident and Fellow Orientation

“…6,[11][12][13] The discussion highlights a patient safety perspective brought forth by the mother and allows for dialogue concerning existing communication and supervision barriers in the delivery of safe patient care and thoughts on improvement strategies. [14][15][16] Much of medical training is focused on the acquisition of knowledge and skills; however, it is the affective domain of learning that is responsible for changing behaviors.…”