2010, Number 5
<< Back
Cir Cir 2010; 78 (5)
Learning from patients’ experience: enhancing patient safety event reporting systems
Greenberg LG, Battles JB, Haskell H
Language: Spanish
References: 27
Page: 463-468
PDF size: 266.41 Kb.
ABSTRACT
Introduction: Everyone has a personal story of an incident in which the healthcare system has caused harm to a family member, friend, or work colleague. In 2004, one in three Americans (34%) said that they or a family member had experienced a preventable medical error; among them, 21% said the error caused “serious health consequences” such as death (8%), long-term disability (11%) or severe pain (16%).
Discussion: The information patients give is important and can be part of a strategic model to make systemic changes to improve health outcomes and patient safety. It has been identified that one of these shortcomings is that patients’ complaints are not considered able to judge technical quality in their experience with care. We argue for an approach which should actively engage patients and their caregivers in contemplating and describing their experiences as a means to gather evidence about risks and hazards in the healthcare setting.
Conclusions: Patients ought to be viewed as partners with health care providers to improve patient safety; selfreports on adverse events can provide useful information that may be incorporated into patient safety event. Data obtained from this strategy should be useful to improve general changes in health care and a better clinical practice based on evidence.
REFERENCES
Kaiser Family Foundation, Agency for Healthcare Research and Quality, and Harvard School of Public Health. National survey on consumers’ experiences with patient safety and quality information, 2004. Available at http://www.kff.org/kaiserpolls/pomr111704pkg.cfm
Weingart SN, Pagovich O, Sands DZ, Li JM, Aronson MD, Davis RB, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005;20:830-836.
Wu AW, Lipshutz AKM, Pronovost P. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008;299(6):685-687.
Wu AW, Phan JC, Pronovost P. Root cause analyses: are we looking for keys under the lamp post? National Patient Safety Fundation. Focus Patient Saf 2008;11:3-5.
National Quality Forum. Safe Practices for Better. Healthcare- 2010 Update: A Consensus Report. Washington, DC: NQF; 2010. Available at www.qualityforum.org/WorkArea/linkit.aspx? LinkIdentifier=id...25690
Mazor KM, Simon SR, Yood RA, Martinson BC, Gunter MJ, Reed GW, et al. Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004;140(6);409-418.
Kohn LT, Corrigan JM, Donaldson MS; Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. A Report of the. Washington, DC: Institute of Medicine, National Academies Press; 1999.
Aspden P, Corrigan JM, Wolcott J, Erickson SM; Committee on Data Standards for Patient Safety, Board on Health Care Services. Patient safety: achieving a new standard for care. Washington, DC: Institute of Medicine/National Academies Press; 2004. Available at http://www.nap.edu/openbook.php?record_id=10863&page=R1
When Things Go Wrong: Responding To Adverse Events. A Consensus Statement of the Harvard Hospitals. Cambridge, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
Weissman JS, Schneider EC, Weingart SN, Epstein AM, David-Kasdan J, Feibelmann S, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med 2008;149(2):100-108.
U.S. Department of Health and Human Services, Office of the Inspector General. Adverse Events in Hospitals: Methods for Identifying Events. Washington, D.C. : U.S. Department of Health and Human Services; 2010.
Berwick D. What ‘patient-centered’ should mean: confessions of an extremist. Health Affairs 2009;28(4):w555-w565.
Berwick, D. Escape Fire: Lessons Learned for the Future of Health Care. New York, NY: Commonwealth Fund; 2002. Available at http://www.commonwealthfund.org/usr_doc/berwick_escapefire_563.pdf
Klitzman R. When Doctors Become Patients. New York, NY: Oxford University Press; 2008.
Quaid D, Thao J, Denham CR. Story power: the secret weapon. J Patient Saf 2010;6(1):5-14.
Mardon R. Survey of Patient Safety Culture in U.S. Hospitals: External Validity Analyses. Presented at the 2008 AHRQ Annual Research Conference, Bethesda, MD. Available at http://www.cahps.ahrq.gov/content/community/events/files/F-3-P_Mardon-Final_fwp.pdf
Brady C, Leape L. Integrating quality and safety with patient-centered care. In: Frampton SB, Charmel P, editors. Putting Patient First. Best Practices in Patient Centered Care. 2nd ed. Derby, CT: Planetree; 2008. pp. 249-265.
Greenberg, MD, Haviland, AM, Ashwood, JS, Main R. Is Better Patient Safety Associated with Less Malpractice Activity? Evidence from California. Santa Monica, CA: RAND Institute for Civil Justice; 2010.
Joint Commission [website]. Facts about Speak Up Initiatives. Available at http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm
National Patient Safety Foundation [website]. Ask me 3. Available at http://www.npsf.org/askme3/
Lazar, A. AHRQ Uses Tools to Educate Consumers. Managed Healthcare Executive [website]. April 1, 2009. Available at http://managedhealthcareexecutive.modernmedicine.com/mhe/Quality+Strategy/AHRQ-uses-tools-to-educate-consumers/ArticleStandard/Article/detail/592262
Hospital Care Quality Information from de Consumer Perspective [website]. CAHPS Hospital Survey. Available at http://www.hcahpsonline.org/home.aspx
Pichert JW, Hickson G, Moore I. Using Patient Complaints to Promote Patient Safety. Advances in Patient Safety: New Directions and Alternative Approaches. Volume 2. Culture and Redesign. AHRQ Publication No. 08-0034-2. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA 2002;287(22):2951-2957.
Hickson GB, Federspiel CF, Blackford J, Pichert JW, Gaska W, Merrigan MW, et al. Patient complaints and malpractice risk in a regional healthcare center. South Med J 2007;100(8):791-796.
U.S. Department of Health and Human Services, Office of the Inspector General, Adverse Events in Hospitals: State Reporting Systems. Washington, D.C. ; U.S. Department of Health and Human Services; 2008.
Weingart SN, Pagovich O, Sands D, Li JM, Aronson MD Davis RB, et al. What can hospitalized patients tell us about adverse events? Learning from patient-reported incidents. J Gen Intern Med 2005;20(9):830-836.