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.
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).
NHS Improvement. Report a patient safety incident. London: NHS Improvement; 2017.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre