Patient Error: A Preliminary Taxonomy

PURPOSE Current research on errors in health care focuses almost exclusively on system and clinician error. It tends to exclude how patients may create errors that influence their health. We aimed to identify the types of errors that patients can contribute and help manage, especially in primary care.METHODS Eleven nominal group interviews of patients and primary health care professionals were held in Auckland, New Zealand, during late 2007. Group members reported and helped to classify types of potential error by patients. We synthesized the ideas that emerged from the nominal groups into a taxonomy of patient error.RESULTS Our taxonomy is a 3-level system encompassing 70 potential types of patient error. The first level classifies 8 categories of error into 2 main groups: action errors and mental errors. The action errors, which result in part or whole from patient behavior, are attendance errors, assertion errors, and adherence errors. The mental errors, which are errors in patient thought processes, comprise memory errors, mindfulness errors, misjudgments, and—more distally—knowledge deficits and attitudes not conducive to health.CONCLUSION The taxonomy is an early attempt to understand and recognize how patients may err and what clinicians should aim to influence so they can help patients act safely. This approach begins to balance perspectives on error but requires further research. There is a need to move beyond seeing patient, clinician, and system errors as separate categories of error. An important next step may be research that attempts to understand how patients, clinicians, and systems interact to cocreate and reduce errors.     

Empowering people to help speak up about safety in primary care: Using codesign to involve patients and professionals in developing new interventions for patients with multimorbidity

Background

Multimorbidity, defined as the presence of two or more long‐term conditions, is increasingly common in primary care, and patients with multimorbidity may face particular barriers to quality of care and increased safety risks due to the complexity of managing multiple conditions. Consistent with calls to directly involve service users in improving care, we aimed to use design materials to codesign new interventions to improve safety in primary care.

Design

We drew on two established methods—accelerated experience‐based codesign and the future workshop approach. We synthesized design materials based on research into the patient experience of safety and multimorbidity in primary care to enable both patients, service users and carers, and primary health‐care professionals to propose interventions to improve care.

Results

Both patients and professionals prioritized polypharmacy as a threat to safety. Their recommendations for supportive interventions were consistent with Burden of Treatment theory, emphasizing the limited capacity of patients with multimorbidity and the need for services to proactively offer support to reduce the burden of managing complex treatment regimes.

Discussion & Conclusions

The process was feasible and acceptable to participants, who valued the opportunity to jointly propose new interventions. The iterative workshop approach enabled the research team to better explore and refine the suggestions of attendees. Final recommendations included the need for accessible reminders to support medication adherence and medication reviews for particularly vulnerable patients conducted with pharmacists within GP practices.     

Healing in primary care: a vision shared by patients, physicians, nurses, and clinical staff

PURPOSE We wanted to understand the views of patients and clinicians on the central concept of healing and to identify major facilitators of and barriers to promoting healing in primary care.METHODS We undertook a qualitative analysis of focus group discussions. Participants were drawn from primary care clinics of a large, integrated, health care system in Washington State in 2005. Nine focus groups included 84 participants: 28 patients, 23 primary care physicians (19 family physicians), 20 registered nurses, 11 licensed practical nurses, and 2 medical assistants. Randomly sampled established patients were aged from 21 to 65 years; 71% were female.RESULTS We found remarkable concordance across focus groups and among types of participants in the definition of healing: Healing is a dynamic process of recovering from a trauma or illness by working toward realistic goals, restoring function, and regaining a personal sense of balance and peace. Healing is a multidimensional process with physical, emotional, and spiritual dimensions. The key themes are as follows: (1) healing is multidimensional and holistic; (2) healing is a process, a journey; (3) the goal of healing is recovery or restoration; (4) healing requires the person to reach a place of personal balance and acceptance; and (5) relationships are essential to healing. Factors that facilitate healing help build relationships, improve communication, and share responsibility between the patient and clinician. Major barriers are logistical factors that limit high-quality time with healing professionals.CONCLUSIONS Patients and health care team members share a vision of healing and agree on ways to enhance the process in primary care.     

From awareness to involvement? A qualitative study of respiratory patients’ awareness of health service change

Background Despite the policy rhetoric, patient involvement in health service decisions remains limited. Highlighted barriers include a concern that most patients are unable to see beyond personal aspects of their care in order to contribute meaningfully to health service development, and a perception that professionals do not welcome patient involvement. Objectives We aimed to explore respiratory patients’ awareness of changes in local health service provision and provide insight into health professionals’ attitudes to engaging patients. Methods Nested within an ethnographic study of health service reconfiguration, we recruited 31 patients with a range of respiratory diseases from four case study areas in England and Wales. Data from telephone interviews, illness diaries and focus groups with patients, and interviews with health professionals and managers were transcribed and analysed using the Framework approach. Results Participants were not only aware of trends in health service provision (e.g. emergence of new professional roles, shift from secondary to primary care) but interpreted changes in the light of local and national events. Despite this awareness, none of the patients was formally involved in service development, though some contributed to local voluntary groups. Professionals generally welcomed the need for patients’ views to be heard. Discussion and conclusions Our data give grounds for optimism. Patients are aware of and interested in a broad range of health‐related issues. Professionals’ motivation to involve patients in service development may be underestimated. Although practical obstacles remain, our findings should encourage the ongoing search for effective models of promoting patient engagement in health‐care services.     

Creating opportunities for patient participation in managing medications across transitions of care through formal and informal modes of communication

BackgroundCommunicating about medications across transitions of care is important in older patients who frequently move between health care settings. While there is increasing interest in understanding patient communication across transitions of care, little is known about older patients'' involvement in formal and informal modes of communication regarding managing medications.ObjectiveThe aim of this paper was to explore how older patients participated in managing their medications across transitions of care through formal and informal modes of communication.MethodsThe study was conducted across two metropolitan hospitals: an acute hospital and a geriatric rehabilitation hospital in metropolitan Melbourne, Australia. A focused ethnographic design was used involving semi‐structured interviews (n = 50), observations (203 h) and individual interviews or focus groups (n = 25). Following thematic analysis, data were analysed using Fairclough''s Critical Discourse Analysis.ResultsData analysis revealed two major discursive practices, which comprised of an interplay between formal and informal communication and environmental influences on formal and informal communication. Self‐created patient notes were used by older patients to initiate informal discussion with health professionals about medication decisions, which challenged traditional unequal power relations between health professionals and patients. Formal prompts on electronic medication administration records facilitated the continuous information discourse about patients'' medications across transitions of care and encouraged health professionals to seek out older patients'' preferences through informal bedside interactions. Environmental influences on communication comprised health professionals'' physical movements across private and public spaces in the ward, their distance from older patients at the bedside and utilization of the computer systems during patient encounters.ConclusionOlder patients'' self‐created medication notes enabled them to take on a more active role in formal and informal medication communication across transitions of care. Older patients and family members did not have continuous access to information about medication changes during their hospital stay and systems often failed to address older patients'' key concerns about their medications, which hindered their active involvement in formal and informal communication.Patient or Public ContributionOlder adults, family members and health professionals volunteered to be interviewed and observed.     

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: A prioritisation nominal group technique

Introduction

Carers of people with mental illness may face distinct challenges, including navigating fragmented health and social services during discharge from mental health hospitals. Currently, limited examples of interventions that support carers of people with mental illness in improving patient safety during transitions of care exist. We aimed to identify problems and solutions to inform future carer-led discharge interventions, which is imperative for ensuring patient safety and the well-being of carers.

Methods

The nominal group technique was used which combines both qualitative and quantitative data collection methods in four distinct phases: (1) problem identification, (2) solution generation, (3) decision making and (4) prioritisation. The aim was to combine expertise from different stakeholder groups (patients, carers and academics with expertise in primary/secondary care, social care or public health) to identify problems and generate solutions.

Results

Twenty-eight participants generated potential solutions that were grouped into four themes. The most acceptable solution for each was as follows: (1) ‘Carer Involvement and Improving Carer Experience’ a dedicated family liaison worker, (2) ‘Patient Wellness and Education’ adapting and implementing existing approaches to help implement the patient care plan, (3) ‘Carer Wellness and Education’ peer/social support interventions for carers and (4) ‘Policy and System Improvements’ understanding the co-ordination of care.

Conclusion

The stakeholder group concurred that the transition from mental health hospitals to the community is a distressing period, where patients and carers are particularly vulnerable to safety and well-being risks. We identified numerous feasible/acceptable solutions to enable carers to improve patient safety and maintain their own mental wellbeing.

Patient and Public Contribution

Patient and public contributors were represented in the workshop and the focus of the workshop was to identify the problems they faced and co-design potential solutions. Patient and public contributors were involved in the funding application and study design.     

Community health‐care planning in Western Australian Country Health Service‐South West: An evaluation of patient views

Aims: To investigate community health patients' impressions of care planning and their relationship with allied health professionals in a rural town in Western Australia. Methods: Focus groups were conducted followed by a survey to identify patients' opinions on care planning and their relationships with health professionals. Results: Focus groups and a survey identified that patients generally had positive attitudes towards their experiences with community‐based allied health professionals. Participants identified some of the attributes that they valued in allied health professionals. Many participants (39%) believed that they had a partnership with the health professional and also valued having a shared decision‐making power with the health professional (46%); however, 17% identified that they would prefer the health professional to assume more of the decision‐making power. Conclusions: More work is needed to create a health culture in which patients want to manage their own health and can develop a relationship with their health professional that allows them to achieve this.     

Putting the ‘patient’ in patient safety: a qualitative study of consumer experiences

Background Although patient safety has been studied extensively, little research has directly examined patient and family (consumer) perceptions. Evidence suggests that clinicians define safety differently from consumers, e.g. clinicians focus more on outcomes, whereas consumers may focus more on processes. Consumer perceptions of patient safety are important for several reasons. First, health‐care policy leaders have been encouraging patients and families to take a proactive role in ensuring patient safety; therefore, an understanding of how patients define safety is needed. Second, consumer perceptions of safety could influence outcomes such as trust and satisfaction or compliance with treatment protocols. Finally, consumer perspectives could be an additional lens for viewing complex systems and processes for quality improvement efforts. Objectives To qualitatively explore acute care consumer perceptions of patient safety. Design and methods Thirty‐nine individuals with a recent overnight hospital visit participated in one of four group interviews. Analysis followed an interpretive analytical approach. Results Three basic themes were identified: Communication, staffing issues and medication administration. Consumers associated care process problems, such as delays or lack of information, with safety rather than as service quality problems. Participants agreed that patients need family caregivers as advocates. Conclusions Consumers seem acutely aware of care processes they believe pose risks to safety. Perceptual measures of patient safety and quality may help to identify areas where there are higher risks of preventable adverse events.     

Culture, language, and patient safety: Making the link.

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a 'resident pathogen' within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture-language-patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.     

Primary care after psychiatric crisis: a qualitative analysis

PURPOSE Patients with serious psychiatric problems experience difficulty accessing primary care. The goals of this study were to assess whether care managers improved access and to understand patients’ experiences with health care after a psychiatric crisis.METHODS A total of 175 consecutive patients seeking care in a psychiatric emergency department were randomly assigned to an intervention group with care managers or a control group. Brief, semistructured interviews about health care encounters were conducted at baseline and 1 year later. Five raters, using the content-driven, immersion-crystallization approach, analyzed 112 baseline and year-end interviews from 28 participants in each group. The main outcomes were patients’ responses about their care experiences, connections with primary care, and integration of medical and mental health care. Scores for physical function and mental function were compared by analysis of variance (ANOVA).RESULTS At baseline, most participants described negative experiences in receiving care and emphasized the importance of listening, sensitivity, and respect. Fully 71% of patients in the intervention group said that having a care manager to assist them with primary care connections was beneficial. Patients in the intervention group had significantly better physical and mental function than their counterparts in the control group at 6 months (P = .03 for each) but not at 12 months. There was also a trend toward functional improvement over the course of the study in the intervention group.CONCLUSIONS This analysis suggests that care management is effective in helping patients access primary care after a psychiatric crisis. It provides evidence on and insight into how care may be delivered more effectively for this population. Future work should assess the sustainability of care connections and longer-term patient health outcomes.     

Nurses’ elicitation of patient error as a practice in training end‐stage renal patients in automated home peritoneal dialysis

As part of a reorganisation of the delivery of health care in Denmark therapies for chronic medical conditions are moved out of hospitals and disease‐specific patient education programmes instituted to train patients to assume responsibility for treating their disease at home, that is, perform tasks and functions traditionally done by healthcare professionals. Drawing on video‐recordings (90:25h) from a programme for self‐management of end‐stage renal disease through automated home peritoneal dialysis, the study employs conversation analysis to examine nurses’ instructional practices for providing patients with the necessary knowledge, skill and competences. Showing training to rely on an error‐based monitoring strategy, the study demonstrates that rather than solely waiting for random errors to emerge, nurses on occasion steer patients towards specific errors to bring about particular instructional opportunities. Surprising given the seriousness of the therapy, this elicitation of error is shown to reflect a deliberate instructional choice; nurses promote select errors to impart patients with an understanding of the procedural logic behind the therapy and medical technology. The study argues that training patients for chronic disease self‐management and providing them with a proficiency level, normally associated with certified professionals, necessitates pushing patients beyond what is strictly accurate and exposing them to medically delicate events.     

Using a tablet application about nutrition in home care—Experiences and perspectives of healthcare professionals

Undernutrition is an extensive problem among patients in community care services. The literature identifies several barriers that hinder health professionals in identifying nutritional problems and providing nutrition interventions. We developed Appetitus, a tablet application (app) focused on nutrition for older adults. Patients used the app, advised by healthcare professionals. In this study with qualitative design, we explored experiences and perspectives of healthcare professionals who used Appetitus when providing home care. We interviewed 24 healthcare professionals individually and in focus groups. We subjected the data to qualitative content analysis. Healthcare professionals used Appetitus as a mediator in dialogues with patients about nutrition. Giving the older adults an active role in nutrition assessment afforded opportunities to strengthen their involvement in care. Registrations of food and drink consumption gave the healthcare professionals insight into patients’ situations and revealed problems of which the healthcare professionals had not been aware. Based on their experience with Appetitus, healthcare professionals suggested using electronic tools to assess and document the nutritional situation of a larger patient group in home care. In future use of Appetitus, healthcare professionals’ levels of knowledge and confidence when advising patients about nutrition must be emphasised and addressed. Barriers such as time constraints and limited continuity of care are also areas that require attention when new nutrition practices are implemented.     

Patient involvement in patient safety: what factors influence patient participation and engagement?

BACKGROUND: Patients can play an important role in improving patient safety by becoming actively involved in their health care. However, there is a paucity of empirical data on the extent to which patients take on such a role. In order to encourage patient participation in patient safety we first need to assess the full range of factors that may be implicated in such involvement. OBJECTIVE: To delineate factors that could affect the participation of the patient in quality and safety issues in their health care. METHOD: Literature review of patient involvement in health care, drawing from direct evidence (specifically from the safety context) and indirect evidence (extrapolated from treatment decision-making research and the wider patient involvement in health care literature); synthesis and conceptual framework developed, illustrating the known and putative factors that could affect the participation of the patient in safety issues in their health care. MAIN RESULTS: Five categories of factors emerged that could affect patient involvement in safety: patient-related (e.g. patients' demographic characteristics), illness-related (e.g. illness severity), health-care professional-related (e.g. health care professionals' knowledge and beliefs), health care setting-related (e.g. primary or secondary care), and task-related (e.g. whether the required patient safety behaviour challenges clinicians' clinical abilities). CONCLUSION: The potential for engaging patients in patient safety is considerable but further research is needed to examine the influences on patient involvement, the limits and the possible dangers. Patients can act as 'safety buffers' during their care but the responsibility for their safety must remain with the health care professionals.     

‘Managing patient involvement’: provider perspectives on diabetes decision‐making

Background Most studies of shared decision‐making focus on acute treatment or screening decision‐making encounters, yet a significant proportion of primary care is concerned with managing patients with chronic disease. Aim To investigate provider perspectives on the role of patient involvement in chronic disease decision‐making. Design A qualitative, grounded theory study of patient involvement in diabetes care planning. Setting and participants Interviews were conducted with 29 providers (19 general practitioners, eight allied health providers, and two endocrinologists) who participated in diabetes care planning. Results Providers described a conflict between their responsibilities to deliver evidence‐based diabetes care and to respect patients’ rights to make decisions. While all were concerned with providing best possible diabetes care, they differed in the emphasis they placed on ‘treating to target’ or practicing ‘personalized care’. Those preferring to ‘treat to target’ were more assertive, while ‘personalized care’ meant being more accepting of the patient’s priorities. Providers sought to manage patient involvement in decision‐making according to their objectives. ‘Treating to target’ meant involving patients where necessary to tailor care to their needs and abilities, but limiting patient involvement in decisions about the overall agenda. ‘Personalized care’ meant involving patients to tailor care to patient preference. Discussion and conclusions Respecting a patient’s autonomy and delivering high‐quality diabetes care are important to providers. At times it may not be possible to do both, so a careful balance is required. Involving patients in decision‐making may be a means to this end, rather than an end in itself.     

Evaluating quality of patient care communication in integrated care settings: a mixed method approach.

BACKGROUND: Owing to the involvement of multiple professionals from various institutions, integrated care settings are prone to suboptimal patient care communication. To assure continuity, communication gaps should be identified for targeted improvement initiatives. However, available assessment methods are often one-sided evaluations not appropriate for integrated care settings. OBJECTIVE: We developed an evaluation approach that takes into account the multiple communication links and evaluation perspectives inherent to these settings. In this study, we describe this approach, using the integrated care setting of Cerebral Palsy as illustration. METHODS: RESULTS: The approach follows a three-step mixed design in which the results of each step are used to mark out the subsequent step's focus. The first step patient questionnaire aims to identify quality gaps experienced by patients, comparing their expectancies and experiences with respect to patient-professional and inter-professional communication. Resulting gaps form the input of in-depth interviews with a subset of patients to evaluate underlying factors of ineffective communication. Resulting factors form the input of the final step's focus group meetings with professionals to corroborate and complete the findings. CONCLUSIONS: By combining methods, the presented approach aims to minimize limitations inherent to the application of single methods. The comprehensiveness of the approach enables its applicability in various integrated care settings. Its sequential design allows for in-depth evaluation of relevant quality gaps. Further research is needed to evaluate the approach's feasibility in practice. In our subsequent study, we present the results of the approach in the integrated care setting of children with Cerebral Palsy in three Dutch care regions.     

Learning From No-Fault Treatment Injury Claims to Improve the Safety of Older Patients

New Zealand’s treatment injury compensation claims data set provides an uncommon no-fault perspective of patient safety incidents. Analysis of primary care claims data confirmed medication as the leading threat to the safety of older patients in primary care and drew particular attention to the threat posed by antibiotics. For most injuries there was no suggestion of error. The no-fault perspective reveals the greatest threat to the safety of older patients in primary care to be, not error, but the risk posed by treatment itself. To improve patients’ safety, in addition to reducing error, clinicians need to reduce patients’ exposure to treatment risk, where appropriate.