Table 26 'Patient's experience of Adverse Events-Surgical Interventions'

PSI 25: Patients Experience of Adverse Events – Surgical Interventions
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
The frequency of harmful surgical adverse events is cause for serious
concern. Patients are an important source of observations and
information about adverse events. The ultimate goal is to achieve the
best care and outcomes for patients each time they are in touch with the
health care system. Thus patient’s experiences of harm due to an
operation are an important measure of patient safety.
Aim of the PSI This PSI aims at surveillance of patient harm due to an operation
experienced by the patients.
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, question 18b
(9;11).
Extent of Clinically
Testing
Attitudes and responses to adverse events have been investigated from
Danish patient’s and the staff’s point of view, using a questionnaire
survey. Patients were asked about their experiences with errors and
staffs handling of errors. Comparison of responses to the same
questions was made between the two groups. Twenty percent of patient
had experiences minor errors and eight percent large errors during
hospitalisation (11).
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. 44% of staff had experienced an error within the last three
months in ambulatory or in-patient care, whereas 13% of the patients
had experienced an error. By the description the risk manager found
that 44% of the patient reported errors could be classified as
dissatisfaction. One percent of staff had experienced an erroneous
surgical procedure. Three percent of in-patients and 0.3% of staff has
experienced an error related to anaesthesia. 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).
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
69
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Number of patients experiencing a harmful adverse event due to an
operation per 1000 operation procedures.
Numerator Description Number of patients experiencing a harmful adverse event due to an
operation.
Denominator Description Number of operation procedures.
Data Source Administrative data and/or Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The qualitative and quantitative impact harmful surgical procedures
make this PSI important in quality and economic improvement
policies.
Care Setting The PSI applies for quality surgical care.
Professionals Responsible
for Health Care
Surgeons, anaesthesiologists and nurses.
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.