One of the important developments in the patient safety field in recent years has been a shift from talking about medical errors to talking about preventable harm. Not all medical errors result in harm; when harm does occur, it is not always the result of a medical error. But preventable harm is, by definition, a medical error.
Moreover, preventable harm is not always physical. A recent study assessing patients’ perceptions of breakdowns in care included emotional distress and “life disruption” in its definition of harm. We have also seen recent work advocating for health care organizations to collect and assess the severity of emotional harm and disrespect in their organizations.
A recent public opinion survey adds to what we know about patients’ perceptions of medical error, harm, and disrespect. Conducted as a project of the IHI/NPSF Lucian Leape Institute in partnership with NORC at the University of Chicago, the survey polled 2,500 adults representative of the US population to gain insights into how many people perceive medical errors in their care, what the nature of the errors are, what settings they occur in, and how patients experience harm.
Some of the survey’s findings support what we already know or theorize about medical errors. For example, most respondents who experienced a medical error said it occurred in an outpatient setting. Hospitals have conducted much of the patient safety work done over the years, and we have seen progress in areas such as reducing hospital-acquired infections. Most care today, however, is provided outside of hospitals, where the risk of safety lapses has not been so widely addressed.
Similarly, the survey shows diagnostic errors to be among the most common, with 60 percent of those who experienced an error saying it was diagnosis related. This is in line with other research showing missed, delayed, or wrong diagnoses to be among the most cited reasons for malpractice claims.
One of the most interesting findings, however, is that nearly 40 percent of respondents who experienced a medical error noted “being treated disrespectfully” as part of that experience.
What does it mean to be treated disrespectfully? Leape and colleagues consider disrespectful treatment to include actions such as disruptive behavior, humiliating or demeaning treatment, passive-aggressive behavior, and appearing dismissive of others’ concerns. Taking a positive tone, another team defines respect as “the actions taken towards others that protect, preserve, and enhance their dignity.”
It would be easy to regard this finding as an artifact of the survey (respondents chose their answers from a lengthy list and could select as many as they felt applied to their situation). In reality, however, lack of respect relates to broader issues influencing care. A recent study linked patients’ observations of surgeons showing disrespect (to patients or to colleagues) with an increased risk of postoperative complications.
No one goes into medicine planning to be disrespectful, but time pressures and heavy panels of patients can create an environment that can challenge our professionalism. Moreover, patients sense when their clinicians suffer from burnout and may, as a result, be reluctant to ask questions or raise concerns, contributing to communication breakdowns. Burnout also impacts cognition, further upping the risk of error.
The Occupational Safety and Health Administration (OSHA) and others have shown that health care workers are themselves at high risk of physical, emotional, and psychological injury, which also contribute to burnout. As Don Berwick notes in an IHI white paper, “the gifts of hope, confidence, and safety that health care should offer to patients and families can only come from a workforce that feels hopeful, confident, and safe.”
While lack of respect and emotional harm may be relatively new concepts in patient safety, we need to recognize that they are factors that can affect clinicians, staff, patients, and family members. Demonstrating respect, and building trust as a result, is essential to improving patient safety and will prove to be foundational to organizations seeking to engage patients, improve the patient experience, reduce burnout, and create joy in work.
Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.