Table 3 'Patients Experiencing Adverse Events'

PSI 3: Patients experiencing Adverse Events
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
The ultimate goal is to achieve the best care and outcome for patients
each time they are in touch with the health care system. The frequency
of adverse events is cause for serious concern. A comprehensive
approach to reduce adverse events involves not just health care
organisations but patients as well as patients are an important source of
observations and information about adverse events, though. All though
it is a known fact within patient safety experts that patients
comprehend adverse events as errors, patient’s experiences of adverse
events is considered important as a source for identifying areas for
improvement. Thus patient’s experience of adverse events is an
important measure of patient safety.
Aim of the PSI This PSI aims at surveillance of patient’s experience of the presence of
adverse events (e.g. in diagnosing, medication, procedure, and
communication).
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital (9).
Extent of Clinically
Testing
By using a questionnaire attitudes and responses to adverse events
were investigated from the patient’s and the staff’s point of view.
Patients were asked about their experiences with adverse events and
staffs management of adverse events. Comparison of responses to the
same questions was made between the two groups. Twenty percent of
patient had experienced minor adverse events and eight percent large
adverse events during hospitalisation (9).
Another Danish study using mailed questionnaires estimated the
incidence of medical errors; also the extent of agreement between
patients and staff of the type of error was investigated. Errors were
described in free text by informants and rated in categories by a risk
manager. Of the staff 44% had experienced an error within the last
three months in ambulatory or in-patient care, whereas 13% of the
patients had experienced an error. The most frequent error experienced
by staff was: “wrong medicine” and by patients “delayed diagnosis”.
By the descriptions the risk manager found that 44% of the patient
reported errors could be classified as dissatisfaction. The researchers
concluded that patients typically find it difficult to distinguish between
an error and their dissatisfaction, highlighting a need for firm criteria if
patients are to report errors as a basis for improvements. Comparison
of error rates between patients and staff – and indeed between hospitals
- will be misleading until these criteria are reliable and validated (10).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
11
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-Wide PSI.
Data definitions Number of patients experiencing an adverse event per 1000 discharges.
Numerator Description Number of patients experiencing an adverse event during
hospitalisation.
Denominator Description Number of patient’s discharges from hospital
Data Source Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The qualitative and quantitative consequences of adverse events make
this PSI important in quality improvement policies.
Care Setting The PSI applies institution-wide.
Professionals Responsible
for Health Care
All authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be good.
Scoring Scoring according to the manual of the Patient’s Experiences
(Satisfaction) Survey.