| Primary Author: | Madelene Ottosen, MSN, RN |
| Co-Principal Investigators/Collaborators: | Jason Etchegaray, PhD, Landrus Burress, MS, MPH, Allison Ottenbacher, PhD, Eric Thomas, MD, MPH |
| Organization | University of Texas Health Science Center Houston |
Abstract
Purpose
Identify advantages, barriers, and methods for involving patients in the process of learning from errors.
Background
Patient safety can be improved by involving patients as active participants in healthcare processes.1-2 For example, patients experiencing a medical error might play an integral role in improving future patient safety.3-5 However, they are not typically asked for their input or interpretation of the error.4
Materials & Methods
We conducted a two-phase project. Phase I consisted of 28 qualitative interviews of hospital administrators, risk managers, clinicians, and patients about their perceptions of the error analysis process. Results from Phase I framed the foundation for Phase II, which consisted of a conference of 26 experts in error disclosure and patient advocacy who generated potential solutions for post-error involvement of patients.
Results
Themes from the Phase I interviews revealed patients want inclusion in the error disclosure process because they might be able to provide useful information to caregivers and administrators. Caregivers want to include patients by getting their perspective about why the event happened and recommendations about how to prevent error recurrence. In Phase II experts discussed patients need time to process the error and heal; an ability to talk freely about concerns/fears and to ask questions about the error; answers to questions in lay language and to hear an apology. Caregivers need a safe environment to discuss error without blame; time, confidence and skills to effectively communicate with patients and emotional support for their role in the error. Considerations for the level of harm and the fear of legal action would impact the type and timing of involvement.
Conclusion
Key stakeholders in the error analysis are open to the involvement of all interested parties in learning from errors. Plausible options to involve patients and families in error analysis must take into consideration the needs of the stakeholders, the type of error and perceived fears of legal action in designing effective strategies.
Bibliography
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Davis, R.E., Jacklin, R., Sevdalis, N., & Vincent, C.A. (2007).Patient involvement in patient safety: what factors influence patient participation and engagement? Health Expectations, 10,259-267.
Delbanco, T., & Bell, S.K. (2007). Guilty, afraid, and alone – struggling with medical error. New England Journal of Medicine, 357,1682-1683.
Fowler, F.J., Epstein, A., Weingart, S.N, Annas, C.L., Bolcic-Jankovic, D., Clarridge, B., Schneider, E.C., & Weissman, J.S. (2008) Adverse events during hospitalization: results of a patient survey. Journal on Quality and Patient Safety, 34:583-590.
© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).