TITLE PAGE - BMJ Quality & Safety



Appendix 1

Studies on perception of safety by residents of developed countries.

|Source |Study object |Methodology |Sample size (Res-ponse rate) |Sample origin |Results |Conclusions |Recommendations | |Experiences and perceptions

|Daniel et al. 1999 |Experience of patients who filed a complaint |Participants were sent by mail a 32-item questionnaire which asked for a description of the incident leading to the complaint. |n = 500

(63%) |Patients with complaints managed by Health Care Complaints Commission (HCCC), in New South Wales (Australia) |A total of 64% of patients complained of the healthcare; 22% of how they were treated and 14% of lack of ethics. A total of 37% of the complaints were rejected, 2% had unknown results. Some 40% of patients thought the physician had been sanctioned. |Although patients believed they were doing the right thing by filing the complaint, most were not satisfied with the results and expected more convincing actions. Most wanted a punishment or a disciplinary action for the physician. Although complaints for clinical incidents are less common than those related to communication or personal ethics problems, the former are more likely to end in litigation. |Further knowledge of what people consider to be a lack of good medical practice is needed. Also, to understand patients’ expectations and to assess what they can legitimately accomplish is required. | | |Kaiser Family Foundation 2000 |AE experiences and opinions. |Telephone survey for patients and mail or online survey for physicians.

Firstly, respondents were asked about satisfaction with health care system, two mains problems of health care, and their knowledge about AE meaning. After, a definition of medical error was given, and they were asked closed-ended questions regarding preventable AE. These questions explored perceived frequency of AE, deaths due to them, causes of serious AE (either individual professionals or institutions) and a ranking of AE, effectiveness of possible solutions, confidentiality vs release of reports of AE, disclosure of AE, and safety depending on the hospital size. Also, two vignettes depicting a medication error with good and bad outcomes were presented. Then, they were asked about experiences of AE. |n= 2038

(831 physicians, and 1207 members of the public)

|American public and physicians |42% of the public had experienced an AE either in their own care or in a relative care. A total of 89% support that physicians should disclosure a serious AE. The public rated as the most effective solutions to prevent AE the following: spending more time with the physician (78%), requiring hospitals to develop systems to avoid AE (74%), improving training of health professionals (73%), and use only doctors specially trained in intensive care medicine or units (73%).Some |If information regarding quality levels of healthcare services or plans was available, patients would base their choice of medical insurance on that information. |The physician’s level of qualification is key to determining health care quality. | | |Adams and Boscarino 2004 |AE experienced in the household along their lives and in the last 5 years |Telephone survey

Research questions were: ‘How many persons reported that someone in their household experienced a medical error?’, ‘What were the key correlates of these errors?’, ‘Have you or anyone in your house hold ever suffered injury or harm that resulted from a medical error?’ Respondents were asked if the household AE occurred < 5 years ago, and about the type of error (medication, surgical, or diagnostic).

The authors focused particularly on whether being more informed about health care was related to a lower risk AE.

|n= 1001

(53%) |Adult population living in the state of NY (US) |A total of 21% of the residents reported an AE had suffered by themselves or someone in their household (95%CI 18.3-24.0).

11.4% of the households had experienced an AE in the past 5 years (95%CI 9.2-13.6). |In 1/5 of New York homes people had suffered an AE, 1/10 in the last 5 years. The likelihood of informing of an AE would increase if people had greater knowledge of healthcare. |It is important to establish AE predictors in clinical histories or ones reported by patients in surveys, and also to analyze the specific features of the AE experienced by the people surveyed and their relatives. | | |Kuzel et al. 2004 |Main AE, types of AE and related harm in primary care |In-depth interviews.

The authors solicited narratives of preventable incidents in primary care that resulted in a perceived harm, based in a given broad definition or error. Respondents were asked to describe both the incident and the harm with as many additional stories as they could recall, helped by a cue card listing steps in primary care. |n=38 inter-

views |Residents in Virginia and Ohio

(US) |The 38 narratives related 221 incidents. 170 of them were linked to specific harms.

82.4% of the incidents involved breakdowns in the clinician-patient relationship, and 63.3% in access to physicians.

The majority of the referred harms were psychological (70%). |Patients’ accounts focus on psychological and emotional harm caused by medical errors, contrary to the current concern about pharmacological and surgical AE. Errors patients were related to access difficulties and deterioration of physician-patient relationship, rather than technical errors in diagnosis and treatment. |System flaws must be explored and fixed. It is also necessary to reform medical education, healthcare financing and also to change the way in which healthcare-related harm is dealt with, so as not to damage the physician-patient relationship. | | |Vander-heyden et al. 2005 |Perceptions regarding avoidable AE and personal and relatives’ experiences along their lives. |Phone survey, with content analysis for open questions.

Closed-ended questions elicited perceptions of preventable AE. Respondents were asked if they or a family member had ever experienced a preventable AE. Further closed-ended questions explored health consequences, and persons or institutions responsible of the error. Open-ended questions were: ‘What was the error?’, ‘What do you think caused the error?’, ‘How could the error have been prevented?’ |n= 1500

(55%) |Residents in Alberta (Canada) |A total of 37.3% of citiziens reported a preventable AE experienced in their own or family member’s care.

|People blame physicians first and after the system. They are more concerned about the process in which the AE occurs than about the AE itself. They advocate a patient-centered health care system and think that coordination between physicians should be strengthened in order to improve health care quality and reduce the incidence of AE. |Diverse perspectives should be combined in order to understand avoidable AE and promote initiatives on patient safety. The patient’s perspective is to play a key role in research studies and proposals in order to gain his/ her trust and safety. | | |Agoritsas et al. 2005 |AE frequency reported by recently discharged patients and correlates of AE. |Mail survey

Two items were taken from the Picker patient opinion instrument, regarding if the patient had felt treated with respect and dignity during the hospital stay, and the evaluation about global rating of hospital care. The authors developed a list of 27 AE that are noticeable to patients and that occur commonly in a general hospital, including interpersonal problems, medical complications, and health care process problems. |n = 2156

(70%) |Patients discharged from a University Hospital (Switzerland) |Slightly over half of the respondents (50.6%) reported at least one AE.

There was an association of dissatisfaction with interpersonal problems (OR=1.6 CI 95% 1.3-1.8) and process-related problems (OR=1.5 CI 95% 1.3-1.9).

|Patients can report AE occurring during the healthcare in the hospital. These AE occur in half the hospitalizations and produces a negative impact on satisfaction. |Patient AE notification can be a quantitative indicator of quality and safety. | | |Burroughs et al.2005 |Perception of safety when medical errors occur. |Phone interviews.

The main questions addressed were: ‘How safe do patients in Emergency Department (ED) feel from medical errors, and what types of errors are of greatest concern?’, ‘How are these concerns related to patient and hospital characteristics?, ‘What is the relationship between patient concern about medical errors and outcomes such as satisfaction and willingness to return for future care?’ Patients were asked about 23 items assessing satisfaction with an ED experience. Also, they were asked to rate the overall level of medical safety perceived during their ED stay on a five-point scale, and whether there was a specific time during their ED stay they were concerned about 8 possible AE. |n= 1262

(61%) |Patients from 12 Emergency Departments (US) |A total of 88% of the patients considered safety to be satisfactory when faced with medical errors. A total of The perception of safety was correlated with the wish to return to or recommend the ED (R2=0.57, p ................
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