HEALTH INDUSTRY ONLINE - The Importance of Creating Patient-Centered Safety Programs

Reports released in recent years regarding the incidence and frequency of medical errors have shocked the nation. Perhaps the most widely known of these reports has been the study entitled To Err Is Human: Building a Safer Health System, published approximately seven years ago by the Institute of Medicine's Committee on Quality of Health Care in America, which estimated that up to 98,000 Americans die each year as a result of preventable medical errors.¹ As a result of these reports as well as extensive media coverage of the issue, the public's concern regarding the threat of potential medical errors is at all time high. Recent surveys show that the public has serious concerns about medical safety, with approximately 75% of respondents stating that they would be very concerned about a medical error if hospitalized.²

Now, however, a study recently authored by Thomas E. Burroughs, Ph.D., et. al. and published by the Joint Commission on Accreditation of Health Care Organizations in the January 2007 edition of its Journal on Quality and Patient Safety (hereinafter referred to as "the Burroughs study") reports that the types of events that patients perceive and report as medical errors are probably, in fact, very different from what clinicians view as medical errors.³ Moreover, the Burroughs study appears to demonstrate that patients' definition of what constitutes "medical error" is probably much broader than the traditional medical definition, and that patients often think of such so-called "medical errors" in terms of broad categories of unsatisfactory health care experiences rather than specific clinical events or physical outcomes.

Unquestionably, it is important for health care providers to develop and implement safety programs that help prevent or at least reduce the incidence of true medical errors. In addition, however, studies such as the recent study released by the Joint Commission demonstrate the need for health care providers to be aware of the public's perception of health care quality and safety and patients' perception of what constitutes "medical error," and to attempt to respond to such concerns through patient-centered safety programs. Such programs should provide a mechanism for recognizing and responding to patients' concerns regarding their health care experience, including not only those which involve concerns over real medical error but also those which involve concerns regarding events or issues which do not involve real error but which nonetheless are important to the patient. Such patient-centered safety programs should help prevent real medical errors and, at the same time, through patient education, reduce the gap that exists between patient perception and medical reality, thereby improving patients' satisfaction with their overall health care experience.

Background on the Recent Study

The purpose of the Burroughs study was to better understand patients' definitions of and concerns about medical errors while hospitalized. In order to conduct the study, 1,656 patients at 12 acute care hospitals were surveyed. The patients were randomly selected from all patients discharged from 12 acute care hospitals. The hospitals from which the patients were selected were all part of the same midwestern health system but they consisted of a variety of sizes and types of facilities, including one large adult academic hospital (900 beds), three large metropolitan hospitals (300-500 beds), three mid-size metropolitan hospitals (70-140 beds), four rural hospitals (20-70 beds), and one academic children's hospital (235 beds). Data weighting techniques were applied to make sure that the results were representative of the entire hospitalized population, not only in terms of age and gender but also in terms of proportionate volume of patients discharged from each hospital within the system during the time period studied.

Patients were asked to address four questions: (1) How do patients define medical errors? (2) How safe do hospitalized patients feel from medical errors, and what types of errors are of greatest concern? (3) Are concerns about medical errors related to specific patient and hospital characteristics? (4) What is the relationship between patients' concerns about medical errors and outcomes such as satisfaction and willingness to return for future care?

How Patients Define Medical Errors

Results of the Burroughs study indicate that familiarity with how patients define medical errors is essential. Like health care providers, patients' definition of medical errors includes events such as medication errors, equipment malfunctions, misdiagnosis, being mistaken for another patient, and receiving the wrong test or procedure.⁴ However, the patients' definition of medical errors was much broader and included not only clinical mistakes, but also staff not communicating effectively, not taking the time to listen to patients, and not being responsive. In addition, patients included falling and being injured and broad categories such as "mistakes by nurses" and "errors by physicians" as medical errors. These findings are consistent with previous research, which has demonstrated that patients and physicians agree that medical errors could be defined as deviations from the standard of care, but that patients' definition of error is more expansive and includes communication problems with their health care providers and situations when something "didn't feel right."⁵

Patients' Overall Perception of Medical Safety

In addition, the Burroughs study emphasizes that it is necessary to have an understanding of patients' overall perception of medical safety: 94% of the patients indicated their medical safety had been good, very good, or excellent; however, 39% of the respondents reported that they had experienced at least one of the following seven concerns during their hospital stay: (1) a medication error, (2) problems with medical equipment, (3) a mistake by the nursing staff, (4) a mistake by the physicians, (5) being mistaken for another patient, (6) wrong test/procedure, and (7) being misdiagnosed.⁶

The frequency of concerns varied considerably by patient ethnicity and age, but not by sex or payer-type.⁷ African-Americans reported feeling significantly more concerned about their safety than did Asians and Caucasians.⁸ Concerns were highest for parents of pediatric patients and for patients between the ages of 30 and 59, while the fewest concerns were reported by patients in their 20s and those older than 59.⁹

The frequency of concerns was also associated with the type of hospital and the length of stay. Concerns were significantly higher amongst parents of pediatric patients, followed by patients at the large academic institution, the large metropolitan hospitals, and midsize metropolitan hospitals. Interestingly, the level of concern was lowest amongst patients at the small rural hospitals, particularly for medication errors, physician mistakes, and having the wrong test/procedure.¹⁰ Acuity and duration of illness were also significant factors: The incidence of concern was highest among patients with longer lengths of stay, those admitted through the emergency department, and those with a serious illness and/or at a greater mortality risk.¹¹ Understanding how levels of concern vary across these groups may help health care providers tailor their efforts to meet the specific needs of these different groups of patients.

Relationship Between Patients' Concerns and Willingness to Recommend the Hospital

Previous studies have demonstrated that patient complaints about the quality of service, such as communication and responsiveness, are directly correlated to subsequent litigation. ¹² The Burroughs study confirmed what has also been demonstrated by other studies (and which is only logical): that patients' overall perception of health care quality and safety is directly linked to patient satisfaction and willingness to recommend the facility to family and friends. The strongest correlation was found between patient satisfaction and the compassion with which care was provided and nursing care delivery.¹³ Moreover, the following five concerns are highly predictive of reduced patient satisfaction: (1) nursing errors, (2) being misdiagnosed, (3) being mistaken for another patient, (4) having the wrong test or procedure, and (5) physician errors.¹⁴ Patients who experience one of those five concerns were less willing to recommend the hospital or return to that hospital for subsequent care.¹⁵

Conclusion

The Burroughs study, recently published by the Joint Commission, demonstrates the importance of developing patient-centered safety programs in which patients are truly involved in the recognition and prevention of medical errors. It is important to recognize that patients define medical errors much more broadly than physicians and other health care providers. Accordingly, it appears that there is a need to educate patients (and the general public) regarding what actually constitutes real medical error. However, patients' non-traditional definitions of medical errors must not be dismissed, especially in light of the apparent correlation between patient satisfaction, willingness to recommend the facility, and subsequent litigation. Rather, patients should be given an opportunity to express their questions and concerns openly, and, at the same time, see that their health care providers are willing and able to adequately respond to their questions and concerns. Moreover, given that patients' concerns about medical errors seem to vary by types of patients and types of hospitals, hospitals should tailor their safety programs to address the individual needs of these groups. As an example, hospitals may want to consider using questionnaires or other techniques to evaluate patients' assessment of their health care experience, including whether patients experienced concern about medical errors.