Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand

Humanising processes after harm part 2: compounded harm experienced by patients and their families after safety incidents

Background

Healthcare organisations risk harming patients and their families twofold. First, through the physical, emotional and/or financial harm caused by safety incidents themselves, and second, through the organisational response to incidents. The former is well-researched and targeted by interventions. However, the latter, termed 'compounded harm' is rarely acknowledged.

Aims

We aimed to explore the ways compounded harm is experienced by patients and their families as a result of organisational responses to safety incidents and propose how this may be reduced in practice.

Methods

We used framework analysis to qualitatively explore data derived from interviews with 42 people with lived or professional experience of safety incident responses. This comprised 18 patients/relatives, 16 investigators, seven healthcare staff and one legal staff. People with lived and professional experience also helped to shape the design, conduct and findings of this study.

Findings

We identified six ways that patients and their families experienced compounded harm because of incident responses. These were feeling: (1) powerless, (2) inconsequential, (3) manipulated, (4) abandoned, (5) de-humanised and (6) disoriented.

Discussion

It is imperative to reduce compounded harm experienced by patients and families. We propose three recommendations for policy and practice: (1) the healthcare system to recognise and address epistemic injustice and equitably support people to be equal partners throughout investigations and subsequent learning to reduce the likelihood of patients and families feeling powerless and inconsequential; (2) honest and transparent regulatory and organisational cultures to be fostered and enacted to reduce the likelihood of patients and families feeling manipulated; and (3) the healthcare system to reorient towards providing restorative responses to harm which are human centred, relational and underpinned by dignity, safety and voluntariness to reduce the likelihood of patients and families feeling abandoned, de-humanised and disoriented.

Patient perspectives on adverse event investigations in health care

BACKGROUND

Over the last decade attention has grown to give patients and next of kin (P/N) more substantial roles in adverse event investigations. Adverse event investigations occur after adverse events that resulted in death or severe injury. Few studies have focused on patient perspectives on their involvement in such investigations. The present study sets out to investigate how P/N and patient representatives (client councils and the Patient Federation Netherlands) view the involvement of P/N in adverse event investigations, particularly whether and why they want to involved, and how they want to shape their involvement.

METHODS

The study features qualitative data on three levels: interviews with P/N (personal), focus groups with representatives of client councils (institutional), and an interview with the Patient Federation Netherlands (national). Researchers used inductive, thematic analysis and validated the results through data source triangulation.

RESULTS

The initiative taken by the hospitals in this study provided P/N with the space to feel heard and a position as legitimate stakeholder. P/N appreciated the opportunity to choose whether and how they wanted to be involved in the investigation as stakeholders. P/N emphasized the need for hospitals to learn from the investigations, but for them the investigation was also part of a more encompassing relationship. P/N's views showed the inextricable link between the first conversation with the health care professional and the investigation, and the ongoing care after the investigation was finalized. Hence, an adverse event investigation is part of a broader experience when understood from a patient perspective.

CONCLUSIONS

An adverse event investigation should be considered as part of an existing relationship between P/N and hospital that starts before the investigation and continues during follow up care. It is crucial for hospitals to take the initiative in the investigation and in the involvement of P/N. P/N motivations for involvement can be understood as driven by agency or communion. Agentic motivations include being an active participant by choice, while communion motivations include the need to be heard.

Adverse events and perceived abandonment: learning from patients' accounts of medical mishaps

BACKGROUND

Adverse medical events affect 10% of American households annually, inducing a variety of harms and attitudinal changes. The impact of adverse events on perceived abandonment by patients and their care partners has not been methodically assessed.

OBJECTIVE

To identify ways in which providers, patients and families responded to medical mishaps, linking these qualitatively and statistically to reported feelings of abandonment and sequelae induced by perceived abandonment.

METHODS

Mixed-methods analysis of responses to the Massachusetts Medical Errors Recontact survey with participants reporting a medical error within the past 5 years. The survey consisted of forty closed and open-ended questions examining adverse medical events and their consequences. Respondents were asked whether they felt 'that the doctors abandoned or betrayed you or your family'. Open-ended responses were analysed with a coding schema by two clinician coders.

RESULTS

Of the 253 respondents, 34.5% initially and 20% persistently experienced abandonment. Perceived abandonment could be traced to interactions before (18%), during (34%) and after (45%) the medical mishap. Comprehensive post-incident communication reduced abandonment for patients staying with the provider associated with the mishap. However, 68.4% of patients perceiving abandonment left their original provider; for them, post-error communication did not increase the probability of resolution. Abandonment accounted for half the post-event loss of trust in clinicians.

LIMITATIONS

Survey-based data may under-report the impact of perceived errors on vulnerable populations. Moreover, patients may not be cognizant of all forms of adverse events or all sequelae to those events. Our data were drawn from a single state and time period.

CONCLUSION

Addressing the deleterious impact of persisting abandonment merits attention in programmes responding to patient safety concerns. Enhancing patient engagement in the aftermath of an adverse medical event has the potential to reinforce therapeutic alliances between patients and their subsequent clinicians.

Effectiveness of a Patient Safety Incident Disclosure Education Program: A Quasi-Experimental Study

BACKGROUND

The accurate disclosure of patient safety incidents is necessary to minimize patient safety incidents and medical disputes. As prospective healthcare providers, nursing students need to possess the ability to disclose patient safety incidents.

PURPOSE

This study was designed to investigate the effect of a patient safety incident disclosure education program for undergraduate nursing students on participants' knowledge and perception of disclosure of these incidents, attitudes toward patient safety, and self-efficacy regarding disclosure of these incidents.

METHODS

A quasi-experimental study with a nonequivalent pretest-posttest design was conducted on fourth-year undergraduate nursing students recruited between September 6 and October 22, 2021, through convenience sampling from two universities in South Korea. The experimental group (n = 25) received the education program. The control group (n = 25) received educational materials on the disclosure of patient safety incidents only. Knowledge and perceptions of patient safety incident disclosure, attitudes toward patient safety, and self-efficacy regarding incident disclosure were measured. Data were analyzed using descriptive analysis, t test, χ2 test, Fisher's exact test, Mann-Whitney U test, Wilcoxon signed-rank test, and ranked analysis of covariance.

RESULTS

Posttest results revealed knowledge (p < .001), perceptions (p = .031), and self-efficacy (p < .001) with regard to the disclosure of patient safety incidents were all significantly higher in the experimental group than in the control group. Posttest attitudes toward patient safety were not significantly different between the two groups (p = .908).

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The patient safety incident disclosure education program effectively enhances the knowledge, perception, and self-efficacy of nursing students with regard to safety incidents. The findings may be used to improve training and educational programs in nursing colleges and hospitals to improve the knowledge, perception, and self-efficacy of nursing students with regard to disclosing patient safety incidents in clinical settings.

How different countries respond to adverse events whilst patients' rights are protected

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

Patient and Family Involvement in Serious Incident Investigations From the Perspectives of Key Stakeholders: A Review of the Qualitative Evidence

OBJECTIVES

Investigations of healthcare harm often overlook the valuable insights of patients and families. Our review aimed to explore the perspectives of key stakeholders when patients and families were involved in serious incident investigations.

METHODS

The authors searched three databases (Medline, PsycInfo, and CINAHL) and Connected Papers software for qualitative studies in which patients and families were involved in serious incident investigations until no new articles were found.

RESULTS

Twenty-seven papers were eligible. The perspectives of patients and families, healthcare professionals, nonclinical staff, and legal staff were sought across acute, mental health and maternity settings. Most patients and families valued being involved; however, it was important that investigations were flexible and sensitive to both clinical and emotional aspects of care to avoid compounding harm. This included the following: early active listening with empathy for trauma, sincere and timely apology, fostering trust and transparency, making realistic timelines clear, and establishing effective nonadversarial communication. Most staff perceived that patient and family involvement could improve investigation quality, promote an open culture, and help ensure future safety. However, it was made difficult when multidisciplinary input was absent, workload and staff turnover were high, training and support needs were unmet, and fears surrounded litigation. Potential solutions included enhancing the clarity of roles and responsibilities, adequately training staff, and providing long and short-term support to stakeholders.

CONCLUSIONS

Our review provides insights to ensure patient and family involvement in serious incident investigations considers both clinical and emotional aspects of care, is meaningful for all key stakeholders, and avoids compounding harm. However, significant gaps in the literature remain.

A practical example of an open disclosure process for people with intellectual disabilities in the Republic of Ireland

Literature pertaining to open disclosure predominantly refers to acute care settings; this is the case in, for example, the UK, Republic of Ireland, Australia, Korea and the USA. There is, however, a dearth of literature regarding open disclosure related to people with intellectual disabilities. A practice example of open disclosure is presented here, following a serious adverse event in an organisation supporting adults with intellectual disabilities. The aim of the process was to openly disclose in a meaningful way to adults with significant intellectual disabilities and communication difficulties. An apology pathway was developed by a multidisciplinary team based on individual communication needs. A suite of resources was developed including easy read-picture agendas and sign language to support increased understanding of the apology. Service users received the apology first, followed by meetings with their families. This practice example has positive implications for service providers for people with intellectual disabilities.

Medical Dispute Committees in the Netherlands: a qualitative study of patient expectations and experiences

BACKGROUND

Health care incidents, such as medical errors, cause tragedies all over the world. Recent legislation in the Netherlands has established medical dispute committees to provide for an appeals procedure offering an alternative to civil litigation and to meet the needs of clients. Dispute committees incorporate a hybrid procedure where one can file a complaint and a claim for damages resulting in a verdict without going to court. The procedure is at the crossroads of complaints law and civil litigation. This study seeks to analyze to what extent patients and family members' expectations and experiences with dispute committees match the goals of the new legislation.

METHODS

This qualitative, retrospective research includes in-depth, semi-structured, face-to-face interviews with patients or family members who filed a complaint with a dispute committee in the Netherlands. The researchers conducted an inductive, thematic analysis of the qualitative data.

RESULTS

A total of 26 interviews were held with 30 patients and family members. The results showed that participants particularly felt the need to be heard and to make a positive impact on health care. Some wished to be financially compensated, for others money was the last thing on their mind. The results demonstrated the existence of unequal power relationships between participants and both the defendant and dispute committee members. Participants reported the added value of (legal) support and expressed the need for dialogue at the hearing. Participants sometimes experienced closure after the proceedings, but often did not feel heard or felt a lack of a practical outcome and a tangible improvement.

CONCLUSIONS

This study shows that participants' expectations and experiences were not always met by the current set up of the dispute committee proceedings. Participants did not feel heard, while they did value the potential for monetary compensation. In addition, some participants did not experience an empowered position but rather a feeling of a power misbalance. The feeling of a power misbalance and not being heard might be explained by existing epistemic injustice, which is a concept that should be carefully considered in processes after health care incidents.

Adverse event reviews in healthcare: what matters to patients and their family? A qualitative study exploring the perspective of patients and family

OBJECTIVES

Explore what 'good' patient and family involvement in healthcare adverse event reviews may involve.

DESIGN

Data was collected using semi-structured telephone interviews. Interview transcripts were analysed using an inductive thematic approach.

SETTING

NHS Scotland.

PARTICIPANTS

19 interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.

RESULTS

Four key themes were derived from these interviews: trauma, communication, learning and litigation.

CONCLUSIONS

There are many advantages of actively involving patients and their families in adverse event reviews. An open, collaborative, person-centred approach which listens to, and involves, patients and their families is perceived to lead to improved outcomes. For the patient and their family, it can help with reconciliation following a traumatic event and help restore their faith in the healthcare system. For the health service, listening and involving people will likely enhance learning with subsequent improvements in healthcare provision with reduction in risk of similar events occurring for other patients. This study suggests eight recommendations for involving patients and families in adverse event reviews using the APICCTHS model (table 3) which includes an apology, person-centred inclusive communication, closing the loop, timeliness, putting patients and families at the heart of the review with appropriate support for staff involved. Communicating in a compassionate manner could also decrease litigation claims following an adverse event.

Humanizing harm: Using a restorative approach to heal and learn from adverse events

Background

Healthcare is not without risk. Despite two decades of policy focus and improvement efforts, the global incidence of harm remains stubbornly persistent, with estimates suggesting that 10% of hospital patients are affected by adverse events.

Methods

We explore how current investigative responses can compound the harm for all those affected—patients, families, health professionals and organizations—by neglecting to appreciate and respond to the human impacts. We suggest that the risk of compounded harm may be reduced when investigations respond to the need for healing alongside system learning, with the former having been consistently neglected.

Discussion

We argue that incident responses must be conceived within a relational as well as a regulatory framework, and that this—a restorative approach—has the potential to radically shift the focus, conduct and outcomes of investigative processes.

Conclusion

The identification of the preconditions and mechanisms that enable the success of restorative approaches in global health systems and legal contexts is required if their demonstrated potential is to be realized on a larger scale. The policy must be co‐created by all those who will be affected by reforms and be guided by restorative principles.

Patient or Public Contribution

This viewpoint represents an international collaboration between a clinician academic, safety scientist and harmed patient and family members. The paper incorporates key findings and definitions from New Zealand's restorative response to surgical mesh harm, which was co‐designed with patient advocates, academics and clinicians.

Disclosing Adverse Events in Clinical Practice: The Delicate Act of Being Open

Practicing a "safe" disclosure of adverse events remains challenging for healthcare professionals. In addition, knowledge on how to deliver a disclosure is still limited. This review focuses on how disclosure communication may be practiced based on the perspectives of patients and healthcare professionals. Empirical studies conducted between September 2008 and October 2019 were included from the databases PubMed, Web of Science and Psychinfo. After full text analysis and quality appraisal this scoping review included a total of 23 studies out of 2537 studies. As a first step, the needs of patients and the challenges of healthcare professionals with the practice of providing an effective disclosure were extracted from the empirical literature. Based on these findings, the review demonstrates that specific disclosure communication strategies on the level of interpersonal skills, organization, and supportive factors may facilitate healthcare professionals to provide optimal disclosure of adverse events. These may be relevant to provide patients with a tailored approach that accompanies their preferences for information and recognition. In conclusion, healthcare professionals may need training in interpersonal (verbal and nonverbal) communication skills. Furthermore, it is important to develop an open (organizational) culture that supports the communication of adverse events and disclosure as a standard practice.

Epistemic Injustice in Incident Investigations: A Qualitative Study

Serious incident investigations-often conducted by means of Root Cause Analysis methodologies-are increasingly seen as platforms to learn from multiple perspectives and experiences: professionals, patients and their families alike. Underlying this principle of inclusiveness is the idea that healthcare staff and service users hold unique and valuable knowledge that can inform learning, as well as the notion that learning is a social process that involves people actively reflecting on shared knowledge. Despite initiatives to facilitate inclusiveness, research shows that embracing and learning from diverse perspectives is difficult. Using the concept of 'epistemic injustice', pointing at practices of someone's knowledge being unjustly disqualified or devalued, we analyze the way incident investigations are organized and executed with the aim to understand why it is difficult to embrace and learn from the multiple perspectives voiced in incident investigations. We draw from 73 semi-structured interviews with healthcare leaders, managers, healthcare professionals, incident investigators and inspectors, document analyses and ethnographic observations. Our analysis identified several structures in the incident investigation process, that can promote or hinder an actor's epistemic contribution in the process of incident investigations. Rather than repeat calls to 'involve more' and 'listen better', we encourage policy makers to be mindful of and address the structures that can cause epistemic injustice. This can improve the outcome of incident investigations and can help to do justice to the lived experiences of the involved actors in the aftermath of a serious incident.

Patients at the centre after a health care incident: A scoping review of hospital strategies targeting communication and nonmaterial restoration

OBJECTIVE

This study aimed to provide an overview of the strategies adopted by hospitals that target effective communication and nonmaterial restoration (i.e., without a financial or material focus) after health care incidents, and to formulate elements in hospital strategies that patients consider essential by analysing how patients have evaluated these strategies.

BACKGROUND

In the aftermath of a health care incident, hospitals are tasked with responding to the patients' material and nonmaterial needs, mainly restoration and communication. Currently, an overview of these strategies is lacking. In particular, a gap exists concerning how patients evaluate these strategies.

SEARCH STRATEGY AND INCLUSION CRITERIA

To identify studies in this scoping review, and following the methodological framework set out by Arksey and O'Malley, seven subject-relevant electronic databases were used (PubMed, Medline, Embase, CINAHL, PsycARTICLES, PsycINFO and Psychology & Behavioral Sciences Collection). Reference lists of included studies were also checked for relevant studies. Studies were included if published in English, after 2000 and as peer-reviewed articles.

MAIN RESULTS AND SYNTHESIS

The search yielded 13,989 hits. The review has a final inclusion of 16 studies. The inclusion led to an analysis of five different hospital strategies: open disclosure processes, communication-and-resolution programmes, complaints procedures, patients-as-partners in learning from health care incidents and subsequent disclosure, and mediation. The analysis showed three main domains that patients considered essential: interpersonal communication, organisation around disclosure and support and desired outcomes.

PATIENT CONTRIBUTION

This scoping review specifically takes the patient perspective in its methodological design and analysis. Studies were included if they contained an evaluation by patients, and the included studies were analysed on the essential elements for patients.

Medical Error Disclosure: Developing Evidence-Based Guidelines for Chinese Hospitals

OBJECTIVES

This study aims to investigate Chinese individuals' expectations regarding the disclosure of errors that vary in level of harm severity and to develop guidelines for error disclosure.

METHODS

A total of 947 valid responses were collected from a questionnaire survey in 2019, and 220 respondents or their family members had experienced medical errors. The respondents were required to indicate their preferences regarding the disclosure of errors that entail moderate and severe harm. Based on their responses and interviews conducted with several patient safety managers, guidelines for medical error disclosure were developed.

RESULTS

Similar preferences were reported for the disclosure of errors that entail moderate and severe harm. They expected a formal disclosure. Furthermore, they wished to be informed about the error through face-to-face communication in a meeting room immediately after error detection. Moreover, they wanted to be provided with all details about the incident. The health care provider who was involved in the incident, the leader of his/her department/team, the patient safety manager, and top management member were expected to attend the meeting. However, there was a significant difference in who was expected to disclose errors that entail moderate (i.e., the health care provider involved in the incident) and severe (i.e., the leader, top management member) harm.

CONCLUSIONS

Medical error disclosure is not commonly practiced in Chinese hospitals. Therefore, the proposed guidelines could be the first step toward disclosure supporting. In addition, the present findings underscore the importance of cultural sensitivity and error severity in international error disclosure research and practice.

Health practitioner experience of Health and Disability Commissioner investigations

INTRODUCTION The New Zealand Health and Disability Commissioner (HDC) Act 1994 was designed to protect the rights of consumers and provide a fair, simple, speedy, and efficient resolution to complaints. No recent studies have been published about the health practitioner experience of HDC investigations following a patient complaint, and none that include nurses and midwives. AIM To use a restorative inquiry framework to understand the impacts and needs of health practitioners arising from an event that led to an investigation by the HDC during the last 10 years. METHODS A descriptive qualitative approach was used with data collected using semi-structured interviews with doctors, nurses, and midwives (n = 13). The data were analysed using thematic analysis. RESULTS Participants worked in primary care, aged care, and services provided by public hospitals. The emotional impacts arising from the event and investigation were profound, with long-lasting effects on participants' sense of self, reputation, and how, or if, they continued to practice. Participants indicated a need for support from colleagues and employers, a fair and relational investigation process, and a meaningful way of connecting to put things right. DISCUSSION A shift to a restorative approach whereby people involved in a complaint come together to speak truthfully about what happened and its impact on their lives, offers hope for a process that repairs relationships and improves health services. Restorative approaches clarify accountabilities and could lead to more satisfactory outcomes for all parties. This study contributes to emerging thinking about the use of restorative approaches in health-care contexts.

A New Argument for No-Fault Compensation in Health Care: The Introduction of Artificial Intelligence Systems

Artificial intelligence (AI) systems advising healthcare professionals will be widely introduced into healthcare settings within the next 5–10 years. This paper considers how this will sit with tort/negligence based legal approaches to compensation for medical error. It argues that the introduction of AI systems will provide an additional argument pointing towards no-fault compensation as the better legal solution to compensation for medical error in modern health care systems. The paper falls into four parts. The first part rehearses the main arguments for and against no-fault compensation. The second explains why it is likely that AI systems will be widely introduced. The third part analyses why it is difficult to fit AI systems into fault-based compensation systems while the final part suggests how no-fault compensation could provide a possible solution to such challenges.

Assessing Patients' Experiences with Medical Injury Reconciliation Processes: Item Generation for a Novel Survey Questionnaire

BACKGROUND

Many health care organizations want to improve their responses to patients who suffer medical injuries. Their ability to understand how well they meet patients' needs is limited by the lack of suitable instruments for assessing injured patients' experiences.

METHODS

This study aimed to generate items for a patient experience questionnaire that medical facilities can use to assess how well resolution met patients' needs. The Medical Injury Reconciliation Experiences Survey (MIRES) was based on findings from previous studies of New Zealand and American patients' experiences of non-litigation resolution of medical injuries. The researchers performed a content analysis of 24 transcripts from a stratified random sample of 92 interviews from the prior studies. Themes were extracted to develop a draft questionnaire, which was revised following feedback from experts. Cognitive debriefing interviews were conducted with 24 New Zealand and American injured patients.

RESULTS

There were 40 items in the following domains: perceptions of communications with health care providers after the injury (15 items), perceptions of remedial gestures (11 items), indicia of the patient's overall satisfaction with the reconciliation process (4 items), the nature and impacts of the injury (5 items), and patients' characteristics (5 items). Participants' feedback about the questionnaire was predominantly positive. Their suggestions led to 37 revisions.

CONCLUSION

The MIRES was comprehensible and acceptable to this group of post-injury patients. While further testing is desirable, the MIRES offers promise as a practicable approach that health care organizations can use to assess how well their reconciliation processes met patients' needs.

Victims of medical errors and the problems they face: a prospective comparative study among the Dutch population

Background

A large number of studies are devoted to medical errors, but only a few focused on the problem’s victims of these errors face. Prospective comparative studies on this topic are absent. The aim of this prospective comparative study is to fill this gap of scientific knowledge that may help to improve the care for victims.

Methods

Data were collected in the Longitudinal Internet studies for the Social Sciences panel, based on a random sample of the Dutch population. Surveys were conducted in March–April 2018 (T1^response = 82.1%) and March–April 2019 (T2^response = 80.1%). We assessed medical errors and potentially traumatic or stressful events between T1 and T2, and mental health, work, financial, religious, family, legal/administrative and physical problems at T1 and T2 (N^total = 4711).

Results

In total, 79 respondents were affected by medical errors between T1 and T2, and 2828 were not affected by any event. Of the victims, 28% had high PTSD symptom levels at T2. Stepwise multivariate logistic regression entering all problems at T1 and demographics showed that victims compared with controls significantly more often had all assessed problems at T2, except family problems. For instance, victims more often had mental health problems (29.5% vs. 9.3%; adj. OR = 3.04, P = 0.002) and financial problems (30.4% vs. 6.6%; adj. OR = 4.82, P < 0.001) at T2.

Conclusions

Victims of medical errors more often face various non-physical problems than others. Care for victims should therefore, besides physical health, also include the assessment and targeting of their problems regarding mental health, work, religion, legal issues and finance.

Openness in the NHS: a secondary longitudinal analysis of national staff and patient surveys

Background

Improving openness—including candour when things go wrong, and willingness to learn from mistakes—is increasingly seen as a priority in many healthcare systems. This study explores perceptions of openness in England before and after the publication of the Francis report (2013), which examined failings of openness at one English hospital. We examine whether staff and patients’ views on openness, and experiences of giving voice to concerns, have changed since the report’s publication for better or worse.

Methods

Organisational-level data was collated for all trusts from the NHS National Staff Survey (2007–2017), NHS Acute Inpatient Survey (2004–2016) and NHS Community Mental Health Service User Survey (2007–2017). Survey items related to openness were identified and longitudinal statistical analysis conducted (piecewise growth curve and interrupted latent growth curve analysis) to determine whether there was evidence of a shift in the rate or direction of change following publication of the Francis report.

Results

For some variables there was a discernible change in trajectory after the publication of the Francis report. Staff survey variables continued to rise after 2013, with a statistically significant increase in rate for “fairness and effectiveness of incident reporting procedures” (from + 0.02 to + 0.06 per year; p < .001). For the patient surveys, the picture was more mixed: patient views about information provided by accident and emergency staff rose from a 0.3% increase per year before 2013 to 0.8% per year afterwards (p < .01), and inpatients being involved in decision making increased from a 0.4% rise per year before 2013 to 0.8% per year afterwards (p < .01); however, there were not rises in the other questions. Mental health patients reported a decrease after 2013 in being listened to (decreasing at a rate of 1.9% per year, p < .001).

Conclusions

Data suggest that the Francis inquiry may have had a positive impact on staff and acute inpatients’ perceptions and experiences of openness in the NHS. However such improvements have not transpired in mental health. How best to create an environment in which patients can discuss their care and raise concerns openly in mental health settings may require further consideration.

Evaluation of a simulation-based Risk Management and Communication Masterclass to reduce the risk of complaints, medicolegal and dentolegal claims

Objectives

To understand clinicians' experiences, learning and professional impacts following participation in a Risk Management and Communication Masterclass (RMCM) designed and delivered by Medical Protection Society. To identify the course's strengths and areas for enhancement.

Design

Mixed method study including semistructured telephone interviews. Interviews were conducted between October and December 2017, 6-30 months after course participation. Data were subjected to a thematic analysis. Quantitative analysis of participants' feedback ratings (n=486) on RMCMs delivered between December 2014 and May 2017 was also undertaken.

Setting

RMCMs were delivered to Doctors and Dentists based in the UK and Ireland and South Africa. Participants: A sample of 12 volunteer doctors (Obstetricians/Gynaecologists, Orthopaedic/Spinal Surgeons, General Surgeons, Paediatricians, General Practitioners) and dentists chosen to represent different clinical specialities accepted the invitation to participate.

Results

Study participants reported examples of person-centred communication skills such as empathy, shared-decision making and managing patient expectations in their workplaces following participation in the RMCM. Many clinicians gave examples describing how they used the communication models they learned when back at work. They also demonstrated a better understanding of the motivations for patients to complain or claim. RMCM course participants' high feedback ratings provided further evidence that the course was valuable and met learning objectives.

Conclusions

It may prove difficult to demonstrate quantitatively that liability improves as a direct result of risk management and communications training. Our results on other dimensions (reactions, learning, behaviour change and impact) suggest that the RMCM has a positive and durable effect based on participant feedback.

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey

Background

How openly healthcare providers communicate after a medical error may influence long-term impacts. We sought to understand whether greater open communication is associated with fewer persisting emotional impacts, healthcare avoidance and loss of trust.

Methods

Cross-sectional 2018 recontact survey assessing experience with medical error in a 2017 random digit dial survey of Massachusetts residents. Two hundred and fifty-three respondents self-reported medical error. Respondents were similar to non-respondents in sociodemographics confirming minimal response bias. Time since error was categorised as <1, 1–2 or 3–6 years before interview. Open communication was measured with six questions assessing different communication elements. Persistent impacts included emotional (eg, sadness, anger), healthcare avoidance (specific providers or all medical care) and loss of trust in healthcare. Logistic regressions examined the association between open communication and long-term impacts.

Results

Of respondents self-reporting a medical error 3–6 years ago, 51% reported at least one current emotional impact; 57% reported avoiding doctor/facilities involved in error; 67% reported loss of trust. Open communication varied: 34% reported no communication and 24% reported ≥5 elements. Controlling for error severity, respondents reporting the most open communication had significantly lower odds of persisting sadness (OR=0.17, 95% CI 0.05 to 0.60, p=0.006), depression (OR=0.16, 95% CI 0.03 to 0.77, p=0.022) or feeling abandoned/betrayed (OR=0.10, 95% CI 0.02 to 0.48, p=0.004) compared with respondents reporting no communication. Open communication significantly predicted less doctor/facility avoidance, but was not associated with medical care avoidance or healthcare trust.

Conclusions

Negative emotional impacts from medical error can persist for years. Open communication is associated with reduced emotional impacts and decreased avoidance of doctors/facilities involved in the error. Communication and resolution programmes could facilitate transparent conversations and reduce some of the negative impacts of medical error.

Third Things as Inspiration and Artifact: A Multi-Stakeholder Qualitative Approach to Understand Patient and Family Emotions after Harmful Events

Patient and family emotional harm after medical errors may be profound. At an Agency for Healthcare Research and Quality (AHRQ) conference to establish a research agenda on this topic, the authors used visual images as a gateway to personal reflections among diverse stakeholders. Themes identified included chaos and turmoil, profound isolation, organizational denial, moral injury and betrayal, negative effects on families and communities, importance of relational skills, and healing effects of human connection. The exercise invited storytelling, enabled psychological safety, and fostered further collaborative discussion. The authors discuss implications for quality/safety, educational innovation, and qualitative research.

Strategies to reduce diagnostic errors: a systematic review

Background

To evaluate the effectiveness of audit and communication strategies to reduce diagnostic errors made by clinicians.

Methods

MEDLINE complete, CINHAL complete, EMBASE, PSNet and Google Advanced. Electronic and manual search of articles on audit systems and communication strategies or interventions, searched for papers published between January 1990 and April 2017. We included studies with interventions implemented by clinicians in a clinical environment with real patients.

Results

A total of 2431 articles were screened of which 26 studies met inclusion criteria. Data extraction was conducted by two groups, each group comprising two independent reviewers. Articles were classified by communication (6) or audit strategies (20) to reduce diagnostic error in clinical settings. The most common interventions were delivered as technology-based systems n = 16 (62%) and within an acute care setting n = 15 (57%). Nine studies reported randomised controlled trials. Three RCT studies on communication interventions and 3 RCTs on audit strategies found the interventions to be effective in reducing diagnostic errors.

Conclusion

Despite numerous studies on interventions targeting diagnostic errors, our analyses revealed limited evidence on interventions being practically used in clinical settings and a bias of studies originating from the US (n = 19, 73% of included studies). There is some evidence that trigger algorithms, including computer based and alert systems, may reduce delayed diagnosis and improve diagnostic accuracy. In trauma settings, strategies such as additional patient review (e.g. trauma teams) reduced missed diagnosis and in radiology departments review strategies such as team meetings and error documentation may reduce diagnostic error rates over time.

Trial registration

The systematic review was registered in the PROSPERO database under registration number CRD42017067056.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0901-1) contains supplementary material, which is available to authorized users.

New Zealand District Health Boards' Open Disclosure Policies: A Qualitative Review

BACKGROUND

New Zealand health and disability providers are expected to have local open disclosure policies in place, however, empirical analysis of these policies has not been undertaken.

AIM

This study aims to (1) examine the scope and content of open disclosure policies in New Zealand (2) compare open disclosure policies in New Zealand, and (3) provide baseline results for future research.

METHODS

Open disclosure policies were requested from all twenty New Zealand District Health Boards in June 2016. A total of twenty-one policies were received, with nineteen policies included in the review. The data were analysed using conventional content analysis. Areas of identified guidance were categorised categorized under the headings: 1) identification of an adverse event, 2) actions before disclosure, 3) disclosure of harm, and 4) actions after disclosure.

RESULTS

A total of forty-six distinct areas of guidance could be categorized under the different phases of the open disclosure life-cycle.

CONCLUSION

This review has identified significant unwarranted heterogeneity and important gaps in open disclosure documents in New Zealand which urgently needs to be addressed. Open disclosure policies which are both flexible and specific should enhance the likelihood that injured patients' needs will be met.

A Multi-Stakeholder Consensus-Driven Research Agenda for Better Understanding and Supporting the Emotional Impact of Harmful Events on Patients and Families

BACKGROUND

The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue.

METHODS

A one-day conference of diverse stakeholder groups to establish a consensus-driven research agenda focused on (1) priorities for research on the short-term and long-term emotional impact of harmful events on patients and families, (2) barriers and enablers to conducting such research, and (3) actionable steps toward better supporting harmed patients and families now.

RESULTS

Stakeholders discussed patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. Stakeholder groups reached consensus, defining four research priorities: (1) Establish conceptual framework and patient-centered taxonomy of harm and healing; (2) Describe epidemiology of emotional harm; (3) Determine how to make emotional harm and long-term impacts visible to health care organizations and society at large; and (4) Develop and implement best practices for emotional support of patients and families. The group also created a strategy for overcoming research barriers and actionable "Do Now" approaches to improve the patient and family experience while research is ongoing.

CONCLUSION

Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.

Patients' Experiences With Communication-and-Resolution Programs After Medical Injury

IMPORTANCE

Dissatisfaction with medical malpractice litigation has stimulated interest by health care organizations in developing alternatives to meet patients' needs after medical injury. In communication-and-resolution programs (CRPs), hospitals and liability insurers communicate with patients about adverse events, use investigation findings to improve patient safety, and offer compensation when substandard care caused harm. Despite increasing interest in this approach, little is known about patients' and family members' experiences with CRPs.

OBJECTIVE

To explore the experiences of patients and family members with medical injuries and CRPs to understand different aspects of institutional responses to injury that promoted and impeded reconciliation.

DESIGN, SETTING, AND PARTICIPANTS

From January 6 through June 30, 2016, semistructured interviews were conducted with patients (n = 27), family members (n = 3), and staff (n = 10) at 3 US hospitals that operate CRPs. Patients and families were eligible for participation if they experienced a CRP, spoke English, and could no longer file a malpractice claim because they had accepted a settlement or the statute of limitations had expired. The CRP administrators identified hospital and insurer staff who had been involved in a CRP event and had a close relationship with the injured patient and/or family. They identified patients and families by applying the inclusion criteria to their CRP databases. Of 66 possible participants, 40 interviews (61%) were completed, including 30 of 50 invited patients and families (60%) and 10 of 16 invited staff (63%).

MAIN OUTCOMES AND MEASURES

Patients' reported satisfaction with disclosure and reconciliation efforts made by hospitals.

RESULTS

A total of 40 participants completed interviews (15 men and 25 women; mean [range] age, 46 [18-67] years). Among the 30 patients and family members interviewed, 27 patients experienced injuries attributed to error and received compensation. The CRP experience was positive overall for 18 of the 30 patients and family members, and 18 patients continued to receive care at the hospital. Satisfaction was highest when communications were empathetic and nonadversarial, including compensation negotiations. Patients and families expressed a strong need to be heard and expected the attending physician to listen without interrupting during conversations about the event. Thirty-five of the 40 respondents believed that including plaintiffs' attorneys in these discussions was helpful. Sixteen of the 30 patients and family members deemed their compensation to be adequate but 17 reported that the offer was not sufficiently proactive. Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.

CONCLUSIONS AND RELEVANCE

As hospitals strive to provide more patient-centered care, opportunities exist to improve institutional responses to injuries and promote reconciliation.