best html templates

Why You Should Listen to Patients After an Adverse Event


A study that interviewed 72 patients and families, each of whom experienced a unique adverse event, concluded that patients and families were able to identify at least one contributing factor related to their adverse event.

There is no doubt that a patient’s input is valuable to practitioners in diagnosing and treating their medical conditions, but how valuable is patient input in analyzing and preventing adverse events? The reporting and learning subgroup of the European Commission’s Patient Safety and Quality of Care Working Group (PSQCWG) suggests that opening up error-reporting and learning systems to patients and families can provide a rich source of information for error analysis and prevention.[1] The PSQCWG found that the quality of patient reports is comparable to that of health care providers, and in some cases, provide more details.[2]

In addition to providing a more detailed narrative of adverse events, patients and family members are also a potentially valuable resource for determining causes of medical errors. A study that interviewed 72 patients and families, each of whom experienced a unique adverse event, concluded that patients and families were able to identify at least one contributing factor related to their adverse event.[3] Because patients and families generally witness the adverse event, are able to provide information about a communication breakdown, and are the only link between various providers, the study’s authors opined that health care organizations might be missing critical information by failing to consult patients and family members in a post-event analysis.[4]

Allowing patient reporting in an error reporting and learning system is one way to capture valuable information from patients and their families. The PSQCWG recognizes that implementation of patient access to error reporting and learning systems can present some difficulties. One difficulty is the lack of patient participation. Member States who introduced patient and family reporting received few reports from patients; however, increased awareness of the system positively affected the patient report volume. Second, patient and family reporting requires a reporting form that uses non-medical terminology and is easily understood by a layperson. Finally, patients must understand that reporting to a learning system is separate from the provider’s complaint system and that the contents of the report, feedback, and analysis will remain confidential and cannot be used in litigation.[5]

[1] Reporting and learning subgroup of the European Commission PSQCWG, Key findings and recommendations on Reporting and learning systems for patient safety incidents across Europe, European Commission, Patient Safety and Quality of Care working group (Nov. 22, 2016, 11:44 a.m.), http://ec.europa.eu/health/patient_safety/docs/guidelines_psqcwg_reporting_learningsystems_en.pdf.

[2] Id.

[3] Etchegaray JM, Ottosen MJ, Aigbe A, et. al., Patients as Partners in Learning from Unexpected Events, Health Services Research (Dec. 7, 2016, 5:04 p.m.), http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12593/full#hesr12593-sec-0023.

[4] Id.

[5] Reporting and learning subgroup of the European Commission PSQCWG, supra.