Patients as Partners in Learning from Unexpected Events

Area of Science:

• Patient Safety
• Healthcare Quality Improvement
• Health Services Research

Background:

• Patient and family involvement in adverse event review is recommended by experts.
• Awareness levels of patients and families regarding adverse event causes are not well understood.

Purpose of the Study:

• To determine if patients/family members can identify contributing factors to adverse events.
• To explore how patients/families become aware of adverse events.
• To understand patient-identified contributing factors and their recommendations for improvement.

Main Methods:

• Semistructured interviews were conducted with 72 patients and family members who experienced adverse events between 1991 and 2014.
• Participants described adverse events across various healthcare settings.
• The primary outcome was the identification of at least one perceived contributing factor to the adverse event.

Main Results:

• All participants identified contributing factors, averaging 3.67 per event.
• Top contributing factors identified were Staff Qualifications/Knowledge (79%), Safety Policies/Procedures (74%), and Communication (64%).
• Patients/families provided recommendations addressing all examined contributing factors.

Conclusions:

• Patients and family members can identify key factors contributing to adverse events.
• Healthcare organizations may miss learning opportunities by not involving patients in the review process.
• Interviewing patients/families about adverse events can enhance organizational understanding and improve safety.