Patient‐Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety

Gillespie, Alex; Reader, Tom W.

doi:10.1111/1468-0009.12338

Cited by 84 publications

(145 citation statements)

References 89 publications

(222 reference statements)

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“…While some studies, including those involving patient-initiated and family-initiated rapid response systems, suggest a potential safety benefit,612 others lack definitive evidence 26. But are we using the right yardsticks?…”

Section: Change the Researchmentioning

confidence: 99%

“…Rather than just responding to individual patients through Patient Relations on a case-by-case basis, several experts now compellingly demonstrate that we should be listening across our organisations through a QI process6 7 to amplify organisational learning. Patient-reported events,6 7 patient-activated and family-activated rapid responses,12 prelitigation notices and claims,41 and other patient feedback should be aggregated and together analysed across departments 6. Taking patient reports seriously and publicising lessons learnt can promote visibility and courage for other patients and families to speak up in the future.…”

Section: Change the Listeningmentioning

confidence: 99%

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Every patient should be enabled to stop the line

Bell

Martínez

2018

BMJ Qual Saf

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Section: Change the Researchmentioning

confidence: 99%

Section: Change the Listeningmentioning

confidence: 99%

Every patient should be enabled to stop the line

Bell

Martínez

2018

BMJ Qual Saf

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“…Individual contributing factors were clustered under domains, categories, and subcategories to improve ease of use of the taxonomy. Where insufficient data were available, we agreed new subcategories through negotiation informed by the patient feedback taxonomy literature . Finally, we grouped the categories into five domains (Table ).…”

Section: Methodsmentioning

confidence: 99%

“…It seeks to move away from improvement based solely on local case‐review, the effectiveness of which is questionable, to a system‐wide approach to learning from harm. Such an approach has been successfully developed to respond to patient complaints, interrogating complaint content for safety improvement opportunities . The development of detailed coding taxonomies was central to enabling the identification of care deficiency ‘hot‐spots’ against which improvement activities could be targeted …”

Section: Introductionmentioning

confidence: 99%

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Using medico‐legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy

Nowotny

Basnayake

Lorenz

et al. 2019

BJOG

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Objective To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement.Design Qualitative descriptive study.Setting Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia.Population All obstetric claims and incident notifications occurring within the date range were included for analysis.Methods De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified.Main outcome measures Rate of claims and notifications, relative frequency of issues, a revised taxonomy.Results A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented.Conclusions Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement.

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Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

et al. 2020

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IMPORTANCE As health information transparency increases, patients more often seek their health data. More than 44 million patients in the US can now readily access their ambulatory visit notes online, and the practice is increasing abroad. Few studies have assessed documentation errors that patients identify in their notes and how these may inform patient engagement and safety strategies. OBJECTIVE To assess the frequency and types of errors identified by patients who read open ambulatory visit notes. DESIGN, SETTING, AND PARTICIPANTS In this survey study, a total of 136 815 patients at 3 US health care organizations with open notes, including 79 academic and community ambulatory care practices, received invitations to an online survey from June 5 to October 20, 2017. Patients who had at least 1 ambulatory note and had logged onto the portal at least once in the past 12 months were included. Data analysis was performed from July 3, 2018, to April 27, 2020. EXPOSURES Access to ambulatory care open notes through patient portals for up to 7 years (2010-2017). MAIN OUTCOMES AND MEASURES Proportion of patients reporting a mistake and how serious they perceived the mistake to be, factors associated with finding errors characterized by patients as serious, and categories of patient-reported errors. RESULTS Of 136 815 patients who received survey invitations, 29 656 (21.7%) responded and 22 889 patients (mean [SD] age, 55.16 [15.96] years; 14 447 [63.1%] female; 18 301 [80.0%] white) read 1 or more notes in the past 12 months and completed error questions. Of these patients, 4830 (21.1%) reported a perceived mistake and 2043 (42.3%) reported that the mistake was serious

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Patient‐Centered Insights: Using Health Care Complaints to Reveal Hot Spots and Blind Spots in Quality and Safety

Cited by 84 publications

References 89 publications

Every patient should be enabled to stop the line

Every patient should be enabled to stop the line

Using medico‐legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy

Frequency and Types of Patient-Reported Errors in Electronic Health Record Ambulatory Care Notes

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