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NIHR Signal Communication problems are top of patients’ concerns about hospital care

Published on 9 April 2019

doi: 10.3310/signal-000758

Patients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues.

When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective.

The study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.

Share your views on the research.

Why was this study needed?

Patient safety is a priority for the NHS, and most trusts will have well-established patient safety incident reporting systems. NHS Improvement, which records safety reports, says a patient safety incident is “any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare.”

There were 1,942,179 patient safety incident reports made in NHS England organisations between April 2017 and March 2018, an increase of 4.3% on the previous year.

However, the accuracy, cost and effectiveness of existing reporting systems have been questioned. Patient experience could be an additional, valuable source of information about safety issues if it was systematically gathered and reviewed.

This study aimed to find out what proportion of patients had concerns about their care, to categorise and understand their concerns, and to assess whether these concerns were in line with the types of patient safety incidents identified by clinicians.

What did this study do?

Trained patient volunteers surveyed inpatients in 33 wards, asking those who had been admitted for at least four hours: “Do you want to tell us something that has concerned you about your care?”

Patients who wanted to report a concern were asked to explain what happened, why they thought it was a safety concern, and what they thought might stop it from happening again. The volunteers surveyed people between May 2013 and September 2014. Patients were over 16 and able to give consent.

Working with researchers, volunteers created 14 categories of concern. Three doctors then reviewed each concern and assessed whether it represented a patient safety incident. The doctors then assessed the seriousness and preventability of each patient safety incident.

Though the study provides insights into patient perspectives, it does not look at the impact of these concerns.

What did it find?

  • Almost a quarter (23%) of patients surveyed raised an incident of concern, with a total of 1,155 incidents provided by 579 patients.
  • The biggest category of concern (21.7%) was communication, either from staff to patient, staff to staff, or patient to staff. Examples included confusion about when patients were due for surgery, with resulting uncertainty about when they could eat, and unnecessary missed meals. One in ten patients raised a safety concern of some kind.
  • Staff shortage issues accounted for 13.2% of concerns. The ward environment was a concern for 12.2% of people, with noise and accessibility cited as examples. Other concerns included a perceived lack of compassion, dignity and respect for patients; medication issues including late, missed or wrong medication; delays in treatment, results or discharge; staff training, food and drink and ward management.
  • The assessing doctors said 406 of the 1,155 incidents reported (35%) qualified as patient safety incidents. They were most likely to identify medication issues as a safety issue, and least likely to flag up concerns about the ward environment. Although communication was the single biggest concern for patients, cited in 251 reports, only 54 of these (21.5%) were seen as patient safety issues by doctors.
  • Of identified patient safety reports, the doctors said 90% were probably or definitely avoidable. They also said 99% were of ‘negligible, minor or moderate’ severity. Only one incident identified by patients was categorised as of major severity.

What does current guidance say on this issue?

NHS Improvement says "Healthcare staff are encouraged where possible to record all patient safety incidents on their local risk management systems" but can report centrally if staff are "unable to access" a local system. It says "Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not."

What are the implications?

The concerns that patients have about their care differ from the safety issues that doctors perceive. Listening to patients’ concerns, even if they seem negligible in terms of current impact, could be a way to flag up and possibly prevent bigger problems which might compromise patient safety. Around one in ten patients in this study reported a concern. This is similar to evidence suggesting that about 10% of patients experience harm, but this study suggests that concerns raised by patients may be different to those reported by staff.

It’s clear from the study that communication is highly important for patients, and feeling listened to might help that interaction. However, routine collection of information about patients' concerns has resource implications and is unlikely to be helpful unless it is analysed in a timely fashion and used as a driver of change.

Citation and Funding

J O’Hara, C Reynolds, S Moore et al. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality and Safety. 2018;27(9):673-82.

The study was funded by the NIHR Programme Grants for Applied Research Programme (project number RP-PG-0108-10049).

Bibliography

NHS Improvement. Report a patient safety incident. London: NHS Improvement; 2017.

Why was this study needed?

Patient safety is a priority for the NHS, and most trusts will have well-established patient safety incident reporting systems. NHS Improvement, which records safety reports, says a patient safety incident is “any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare.”

There were 1,942,179 patient safety incident reports made in NHS England organisations between April 2017 and March 2018, an increase of 4.3% on the previous year.

However, the accuracy, cost and effectiveness of existing reporting systems have been questioned. Patient experience could be an additional, valuable source of information about safety issues if it was systematically gathered and reviewed.

This study aimed to find out what proportion of patients had concerns about their care, to categorise and understand their concerns, and to assess whether these concerns were in line with the types of patient safety incidents identified by clinicians.

What did this study do?

Trained patient volunteers surveyed inpatients in 33 wards, asking those who had been admitted for at least four hours: “Do you want to tell us something that has concerned you about your care?”

Patients who wanted to report a concern were asked to explain what happened, why they thought it was a safety concern, and what they thought might stop it from happening again. The volunteers surveyed people between May 2013 and September 2014. Patients were over 16 and able to give consent.

Working with researchers, volunteers created 14 categories of concern. Three doctors then reviewed each concern and assessed whether it represented a patient safety incident. The doctors then assessed the seriousness and preventability of each patient safety incident.

Though the study provides insights into patient perspectives, it does not look at the impact of these concerns.

What did it find?

  • Almost a quarter (23%) of patients surveyed raised an incident of concern, with a total of 1,155 incidents provided by 579 patients.
  • The biggest category of concern (21.7%) was communication, either from staff to patient, staff to staff, or patient to staff. Examples included confusion about when patients were due for surgery, with resulting uncertainty about when they could eat, and unnecessary missed meals. One in ten patients raised a safety concern of some kind.
  • Staff shortage issues accounted for 13.2% of concerns. The ward environment was a concern for 12.2% of people, with noise and accessibility cited as examples. Other concerns included a perceived lack of compassion, dignity and respect for patients; medication issues including late, missed or wrong medication; delays in treatment, results or discharge; staff training, food and drink and ward management.
  • The assessing doctors said 406 of the 1,155 incidents reported (35%) qualified as patient safety incidents. They were most likely to identify medication issues as a safety issue, and least likely to flag up concerns about the ward environment. Although communication was the single biggest concern for patients, cited in 251 reports, only 54 of these (21.5%) were seen as patient safety issues by doctors.
  • Of identified patient safety reports, the doctors said 90% were probably or definitely avoidable. They also said 99% were of ‘negligible, minor or moderate’ severity. Only one incident identified by patients was categorised as of major severity.

What does current guidance say on this issue?

NHS Improvement says "Healthcare staff are encouraged where possible to record all patient safety incidents on their local risk management systems" but can report centrally if staff are "unable to access" a local system. It says "Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not."

What are the implications?

The concerns that patients have about their care differ from the safety issues that doctors perceive. Listening to patients’ concerns, even if they seem negligible in terms of current impact, could be a way to flag up and possibly prevent bigger problems which might compromise patient safety. Around one in ten patients in this study reported a concern. This is similar to evidence suggesting that about 10% of patients experience harm, but this study suggests that concerns raised by patients may be different to those reported by staff.

It’s clear from the study that communication is highly important for patients, and feeling listened to might help that interaction. However, routine collection of information about patients' concerns has resource implications and is unlikely to be helpful unless it is analysed in a timely fashion and used as a driver of change.

Citation and Funding

J O’Hara, C Reynolds, S Moore et al. What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study. BMJ Quality and Safety. 2018;27(9):673-82.

The study was funded by the NIHR Programme Grants for Applied Research Programme (project number RP-PG-0108-10049).

Bibliography

NHS Improvement. Report a patient safety incident. London: NHS Improvement; 2017.

What can patients tell us about the quality and safety of hospital care? Findings from a UK multicentre survey study

Published on 16 August 2018

J O’Hara, C Reynolds, S Moore, G Armitage, L Sheard, C Marsh, I Watt, J Wright, R Lawton

BMJ Quality and Safety Volume 27 Issue 9 , 2018

Background Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital. Methods Feedback about the experience of safety within hospital was gathered from 2471 inpatients as part of a multicentre, waitlist cluster randomised controlled trial of an intervention, undertaken within 33 wards across three English NHS Trusts, between May 2013 and September 2014. Patient volunteers, supported by researchers, developed a classification framework of patient-reported safety concerns from a random sample of 231 reports. All reports were then classified using the patient-developed categories. Following this, all patient-reported safety concerns underwent a two-stage clinical review process for identification of patient safety incidents. Results Of the 2471 inpatients recruited, 579 provided 1155 patient-reported incident reports. 14 categories were developed for classification of reports, with communication the most frequently occurring (22%), followed by staffing issues (13%) and problems with the care environment (12%). 406 of the total 1155 patient incident reports (35%) were classified by clinicians as a patient safety incident according to the standard definition. 1 in 10 patients (264 patients) identified a patient safety incident, with medication errors the most frequently reported incident. Conclusions Our findings suggest that patients can provide insight about safety that complements existing patient safety measurement, with a frequency of reported patient safety incidents that is similar to those obtained via case note review. However, patients provide a unique perspective about hospital safety which differs from and adds to current definitions of patient safety incidents.

Expert commentary

What makes healthcare unsafe? Is it when people don't communicate, when the ward environment is noisy or when mistakes are made? The answer from this research is “all of these and more”.

Patients and clinical staff have different perceptions (mental models) of patient safety, and both are valid. Currently, the recording and management of safety is skewed towards the clinical model; only 35% of patient safety concerns were identified by clinicians.

Healthcare safety needs to be rebalanced using an approach to understand the experiences and behaviours of all of the stakeholders in the healthcare system.

Sue Hignett, Professor of Healthcare Ergonomics and Patient Safety, Loughborough University

The commentator declares no conflicting interests

Expert commentary

Although most work on patient safety has focused on the role of health care professionals rather than the patient, there is a growing recognition that patients can make a valuable contribution to safety.

This internationally significant study highlights how the types of concerns reported by patients are often disregarded by existing error detection methods. A key challenge in implementing these findings is to ensure that the soft intelligence gathered in patient feedback is integrated with, and given legitimate headroom, alongside information generated by conventional patient safety reporting systems.

It is important that these data are then acted upon to assess and improve services.

Professor Russell Mannion, Chair of Health Systems, University of Birmingham

The commentator declares no conflicting interests