We Want to Know: Eliciting Hospitalized Patients' Perspectives on Breakdowns in Care

Fisher, Kimberly A.; Smith, Kelly M.; Gallagher, Thomas H.; Burns, Laura; Morales, Crystal; Mazor, Kathleen M.

doi:10.12788/jhm.2783

Cited by 23 publications

(23 citation statements)

References 23 publications

(63 reference statements)

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“…Yet they can be ineffective in the absence of strong institutional partnership. 15 , 22 , 36-38 System PFACQS members were engaged as codesigners of several systemwide safety programs, including HRO, 39 CANDOR 36 ,[40][41][42][43] program implementation, our We Want to Know program for patient safety event reporting, [44][45][46][47][48] and most recently, advancing awareness and detection of sepsis. 49 These efforts engaged not only the system PFACQS but also local members to drive systemwide improvements in quality and safety.…”

Section: Lessons Learnedmentioning

confidence: 99%

Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation

Hatlie¹,

Nahum²,

Leonard³

et al. 2020

The Joint Commission Journal on Quality and Patient Safety

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Background: Effective patient-and family-centered care requires a dedication to engaging patients and family members in health system redesign to improve the quality, safety, and experience of care. Provided here are lessons learned six years after establishing an infrastructure of patient and family advisory councils (PFACs) focused on improving health care quality and safety.Context: A large regional health care system with multiple hospitals and ambulatory care delivery sites in the eastern United States adopted a systemwide approach to Patient and Family Advisory Councils on Quality and Safety (PFACQS R ) in 2012.Approach: This conceptual article describes the barriers and facilitators of adopting, implementing, and sustaining the PFACQS model across a large, geographically diffuse health system. Successful strategies that emerged include active board engagement, co-creation and mentorship by experienced patient advocates to support enhanced engagement by local PFACQS community members, and clear alignment with and line of sight on organizational quality and safety goals.Conclusion: Implementing a robust network of PFACQS focused on improving quality and patient safety requires leadership commitment to transparency, as well as mutual respect and trust. Establishing clear guidelines, structures, and processes supports early adoption. Openness to continuous improvement and adaptations are important to program success and contribute to program sustainability.

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Section: Lessons Learnedmentioning

confidence: 99%

Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation

Hatlie¹,

Nahum²,

Leonard³

et al. 2020

The Joint Commission Journal on Quality and Patient Safety

View full text Add to dashboard Cite

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“…Information gathered by patients and their families (P&Fs) gives healthcare organizations an opportunity to learn and improve the system of care. 16,17,18 One way of playing the auditor's role is through the patient-asobserver approach. 19 .…”

Section: Introductionmentioning

confidence: 99%

“…Based on the evidence from real-time safety audits performed during routine work, it is known that such audits can detect a broad range of errors. 18 From this it was considered that the patients' participation in the role of an auditor could assist in identifying gaps in safety and this could lead to work to improve patient safety 6,18 . The safe practices selected for evaluation were patient identi cation, hand hygiene, blood or chemotherapy identi cation, and secondary effects of chemotherapy/transfusion.…”

Section: Introductionmentioning

confidence: 99%

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals

Rincón¹,

Aristorena

Tirapu-Leon

et al. 2020

Preprint

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Background: When there is a gap in professionals’ adherence to safe practices during cancer treatment, the consequences can be serious. Identifying these gaps in order to enable improvements in patient safety can be a challenge. This study aimed to assess if cancer patients and their relatives can be given the skills to audit four safe practices reliably, and to explore whether they are willing to play this new role. Methods: We recruited 136 participants in 2018, from the oncology and haematology day hospital of a tertiary hospital in Spain. Patient identification, hand hygiene, blood or chemotherapy identification, and secondary effects related to transfusion and chemotherapy, were the safe practices selected for evaluation. The study comprised two parts: an interventional educational program and a cross-sectional design to collect data and assess to what degree participants are able to be auditors and are willing to be auditors depending on their characteristics using multivariate logistic regression models. A participant’s auditing skill was assessed pre and post the educational intervention.Results: The model was seeking predictors of being a good auditor and 63 participants (46.3%) were classified as good auditors after the training. To have lower age, to have higher educational level and to have had experience a previous adverse event were associated with a higher probability of being good auditors. Additionally, 106 (77.9%) participants said that they would like to anonymously audit the professionals’ compliance of at least three of four safe practices. The willingness to audit safe practices was differed depending on the safe practice but these differences did not reach statistical significance. Conclusions: The data gathered by patients and relatives acting as auditors can provide healthcare organizations with valuable information about safety and quality of care that is not accessible otherwise. This new role provides an innovative way to engage patients and their families’ in healthcare safety where other methods have not had success. The paper sets out the methods that healthcare organizations need to undertake to enrol and train patients and relatives in an auditor role.

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“…The patient, the provider and environmental factors [2,3] influence the success or failure of information transmission at discharge, increasingly the goal is to discharge patients from the ED as fast as possible with expectations to continue care at home or on the ward. This goal adds significantly to the need of detailed care guidance and instructions [4][5][6].…”

Section: Introductionmentioning

confidence: 99%

Assessing the discharge instructing in the emergency department: Patient perspective

Makinen

Castrèn

Huttunen

et al. 2019

International Emergency Nursing

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The objective of the study is to assess how well the emergency department (ED) personnel succeed in instructing the patient at discharge. Methods: In November and December 2016 at Peijas Hospital ED, Finland, a structured questionnaire was conducted during a phone interview on patients the day after discharge. Results: A total of 132 patients interviewed. Ninety percent had received discharge instructions from the ED staff, most of them (75%) about medication. Almost half of the patients (45%) were satisfied with the communication at discharge, those not satisfied (47%) felt that the staff did not know enough of their background to give discharge instructions. Of the patients, 20% thought that they did not have the opportunity to ask questions during the guidance session, and 41% thought that the session was too short and restricted. Some patients (20%) felt that the instructions were ambiguous, but 63% (83/132) felt they were able to follow them well or very well. Conclusion: The pace of care in the ED is fast and duration of the stay is short. The patients must be able to take responsibility of their self-care. Failure to follow medical discharge instructions could lead to non-compliance. Attention should be paid to enhancing the quality of discharge instructing and the instructions provided by the ED personnel, as recurring visits and inquiry calls add to the ED workload.

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We Want to Know: Eliciting Hospitalized Patients' Perspectives on Breakdowns in Care

Abstract: When asked directly, almost 4 out of 10 hospitalized patients reported a breakdown in their care. Patient- perceived breakdowns in care are frequently associated with perceived harm, illustrating the importance of detecting and addressing these events.

Cited by 23 publications

References 23 publications

Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation

Lessons Learned from a Systems Approach to Engaging Patients and Families in Patient Safety Transformation

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals

Assessing the discharge instructing in the emergency department: Patient perspective

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