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Patients Teach About Error

By Tom A. Augello, CRICO

Related to: Ambulatory, Communication, Diagnosis, Emergency Medicine, Primary Care, Medication, Nursing, Obstetrics, Other Specialties, Surgery

Inpatient or outpatient, patients show they can provide exclusive information about clinical errors.

Commentators

  • Nancy Elder, MD, MSPH; University of Cincinnati; Cincinnati, OH
  • Anton Kuzel, MD, MHPE; Virginia Commonwealth University; Richmond, VA
  • Saul Weingart, MD, PhD; Dana Farber Cancer Institute; Boston, MA

Transcript

Several recent qualitative studies about medical error explore what providers can learn from patients about the quality of their clinical care.

In some of the studies, researchers talked to patients in the hospital, while others focused on the outpatient setting or office practice. Definitions of “error” varied and sometimes were expanded to capture the patient’s perspective.

A striking similarity among the findings suggests that patients can provide useful—and sometimes exclusive—information that may help prevent errors and improve care.

“I think most people who study patient experiences will tell you that people who experience problems, they want to let you know about it.”

Dr. Nancy Elder is an associate professor of family medicine at the University of Cincinnati. Dr. Elder became interested in how people change the way they interact with the healthcare system after a medical error. In a study in the November/December 2005 issue of the Annals of Family Medicine, her team called 132 randomly selected patients on the phone and interviewed 24 who indicated something had gone wrong with their care.

The patients described problems that included administrative issues, such as appointment problems, or rudeness or lying by office staff. And some patients reported serious flaws in clinical care

“The other big areas—and I think most important to physicians—were communication problems, patient/physician communication errors, as well as clinical care.  There were misdiagnoses.  I remember there was a DVT that was misdiagnosed.  There were medication problems, doses cut in half, wrong medications prescribed. There were procedural problems. There was broken equipment.   There were problems with doing procedures.”

What the patients showed Dr. Elder’s team was a spectrum of responses to suffering a medical error. She believes that a better understanding of predictable patient responses can help providers identify an individual patient’s needs and strengthen the clinician/patient relationship.

The patient reactions in Dr. Elder’s study fell into four categories on a spectrum—from avoiding care, to becoming an intense advocate for their own treatment. The largest number of respondents were in the middle of the spectrum, in a category called “anticipation.” These patients tended to take more responsibility for learning about their disease and various options, as well as learning how to work the system.

But in terms of mistrust after a preventable problem—by far the most worrisome response—patients on either end of the spectrum were involved.

“That kind of came out as well, as people were describing their stories to us.  When they were describing things like avoiding, like I just can’t trust anybody anymore.  I’m just not even going to go to the doctor or I am avoiding this part of healthcare.  A lot of times they would avoid it because they just didn’t trust it.  They would also say the same kinds of things about trust when they felt they had to be an advocate or when they started being an active advocate like, you know, healthcare isn’t trustworthy anymore so I really need to get up there and work to change it.  There was more distrust on kind of both ends of that spectrum.”

Learning how patients may change their own behaviors after an adverse event is one way to focus on the needs of an individual patient. Another study published in 2005 in the Journal of General Internal Medicine, found that patients can teach us about the errors themselves. This report concluded that in the in-patient setting, routine interviews with patients can help bring to the surface clinical errors and system flaws that would not have otherwise been known.

Eight percent of 264 patients interviewed for that study reported incidents. And another four percent experienced near miss events, many of which were potentially serious.

The lead author is Dr. Saul Weingart, Director of the Center for Patient Safety at Dana Farber Cancer Institute in Boston:

“So we found that the patients actually did a pretty good job of identifying events that the clinician panel who reviewed the events found credible.  We also found that virtually none of these events were reported in the hospital incident reporting system, but if we looked pretty hard, we could find a substantial number of them in the record.”

Dr. Weingart says any hospital or practice could incorporate routine interviews with patients in efforts to identify errors, near-misses, and system flaws that threaten patient safety.
 
Another study that looked for insights from patients who experienced a medical error suggests that the definition of error or harm makes a big difference.

“Harms are usually defined with a pretty high bar.”

Dr. Anton Kuzel is the Chair of Family Medicine at Virginia Commonwealth University in Richmond, and co-author of the study in Annals of Family Medicine in 2004.

“Permanent disability or death is often used as what is necessary or a precondition for something to be called a harm, at least in some studies.  For me, that’s just setting the bar way too high.”

Dr. Kuzel’s team conducted in-depth interviews with 38 patients, uncovering more than 200 problem incidents in primary care. The definitions were intentionally broad so that the patient’s perspective of medical harm would be captured.

“We talked about problems that occurred in healthcare that resulted in some harm, whether it’s emotional, psychological, physical or even financial (which would lead to, I guess, emotional or psychological distress), which in the judgment of the patient was preventable.  These were patient reports, so whether or not we agreed that it was a preventable harm wasn’t so important as just trying to get those kinds of stories from people. …It elicited a lot of stories of harms, especially psychological harms, that I don’t think we would have gotten had we adopted a narrower definition.”

Patients reported psychological traumas, such as belittlement, as well as physical harms from routine procedures, including pain, bruising, and adverse drug reactions. Dr. Weingart says patients are very attuned to aspects of care that are uncomfortable or inconvenient that clinicians often see as normal.

“For example, an infiltrated IV can often be very worrisome and painful to the patient. But in the grand scheme of things, clinicians often don’t take these events too seriously because they tend to be relatively minor problems that are expected in care. Patients may not expect them, so if we could set the expectations correctly, that might make patients more confident in us and might reduce animosity that develops and make them more tolerant of this kind of thing.”

The perceptions of patients are significant for risk management because patients may file malpractice suits not only when they are physically harmed, but also when they feel disrespected. Dr. Weingart and others also point out that some of the less clinical harms that patients identify can serve as a kind of early-warning or leading indicator of the general safety of a practice or hospital.

“We are doing studies now to try to understand if the service quality deficiencies, that is problems with communication, problems with respect, delays and waits, whether there is a relationship between those kinds of events and problems with the technical care that’s rendered. My own hypothesis is that if you can’t get the waits and delays right and if you can’t get the interpersonal communication stuff right and if the team of clinicians isn’t communicating effectively, that this puts the patients at risk of more serious harm. That’s a hypothesis that’s awaiting data.

Meanwhile, providers may be able to apply insights from these studies to their practices and institutions now. Dr. Elder says that if patients become strong advocates and information-seekers after an adverse outcome, doctors can anticipate that and welcome, rather than reject, those patient overtures.

Dr. Kuzel believes that safety improvements that make the care process more reliable and efficient will not only reduce errors, but also reduce costs and improve job satisfaction over the long run. He has already been influenced by his own research. After hearing his own patients report to him the same complaints as patients in his study, Dr. Kuzel set out to re-design his practice.

“We now have advanced access scheduling.  We have simplified our processes.  We have better mechanisms for insuring continuity of care, and all of those things have clearly made a difference.  Staff, patients and the docs, even with these early changes, are clearly happier than they had been before.”


May 1, 2006
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