|Type of Patient Safety Practice|
|Clinical Practice (CP)||
Related practices from PaSQ database
|“Best fit” category of the reported practice||
|Patient safety theme the SCP/clinical risk management practice is aimed at|
|Patient involvement to improve patient safety, specifically focusing on the communication in the health care environment, as a safety risk – provides evidence from applying the practice to different settings and builds on more complex theoretical models which can be applied in practice.
Communication errors are widely recognised as patient safety risks due to the obvious harmful effects on patient’s health. However, there is a small range of scientific evidence to search into the involvement of patient in relation to the effects of the communication errors (including here the lack of communication), although there are many articles spotting the side effects. Therefore, when performing the literature review, EPF started with more general articles that might include scientific evidence on communication errors/ lack of communication between health professionals and patients, in the inpatient and outpatient environments. Since the literature was poor in providing strong evidence, EPF narrowed down the review, performing analysis of more specific articles pertaining to a specific disease area or setting. In the articles where the evidence was scientifically proved, there was also a clear indication concerning the involvement of patients into addressing the communication errors and further improving patient safety.
|Objective of the CRM practice|
|Involving patients in patients safety to address the communication as a health risk (in the context of current literature review) aims at improving the health status of patients by finding the pathway towards avoiding the risk of medical errors and mediating the patient-healthcare professionals relationship to find the best solutions for the patient in the healthcare process.
However, communicating more effectivelly with patients in the “disclosure conversations requires carefully planned, properly executed (discussions, our note), and responsive to patients’ needs […], which creates possible benefits for both patient safety and litigation risk management”. [p. 22, 4].
“Communication failures, being treated by different physicians at the same time and a frequent prescription change increase the number of these patient errors.
The involvement of patient relies also on the good communication in the partnewrship established between the two partners in the treatment decision for the chronic conditions .
The role of patients should be seen not only from the perspective of “what they say and do to influence a decision, but also by virtue of what they think and feel about their roles, efforts and contributions to decision-making and their relationships with their clinicians” [p. 268, 1].
However, the extent of the patients’ participation depends on how the healthcare system is organised and how clear the responsibilities of the involved actors are designed, as demonstrated in the handover process in five countries from Europe. [p. i89, 2].
|Short description of the CRM practice, including any references for further information|
|The practice is presented as a multifaceted aspect which can be integrated in different environments as the inpatient and outpatient, at the same time considering different medical conditions of patients: diabetes, multiple comorbidities etc.
It also refers to the application in disclosing the errors and the adverse events: “One reform requirement—that hospitals inform patients about quality problems in their medical care—also creates an opportunity for improved patient safety.” [p. 22, 4].
In the case of polimedicated patients with multiple comortbidities, communication failure contributes to the adverse events: “The feeling of not being listened to, the loss of confidence in the physician or the incongruent messages between different professionals were associated with the patient making mistakes.” [p. 59-60, 3], therefore physicians in primary care need to involve more patients in the communication “questions the primary care physician asks the patients, particularly to identify what other drugs the patient may be taking as a result of seeing other physicians. Instruments or written information should be considered to verify in practice what contributes to better communication with the patient […]” [p. 62, 3].
As sugested in the shared decision-making in the clinical context (Charles et al. model) , there is a “need to emphasize the patient–clinician relationship as one of partners in making difficult treatment choices and to add a new component to the shared decision-making approach: the need for an ongoing partnership between the clinical team (not just the clinician) and the patient.” [p. 25, 5].
The description of practice in the handover process emphasizes “the individual
A much broader conceptual framework was developed later to emphasize on the increased potential of patients to be involved in the decision-making, meaning not being only involved in the communication to express their preferences from a range of options , but also to be involved “by virtue of what they think and feel about their roles, efforts and contributions to decision-making and their relationships with their clinicians.” [p. 269, 1].
|Innovator of the SCP, country of origin|
|1. UK, the proposed conceptual framework promotes patient involvement in treatment decision-making through a more active role of clinicians in the process.
2. Sweden, The Netherlands, Spain, Italy and Poland – the handovers between the primary care providers and the inpatient hospitals involve sometimes patients; therefore their responsibility should be clearly presented and communicated.3. Spain – half of most common causes of adverse events, particularly in primary care can be avoided based on a good communication between patient and physician.4. USA – presents a model on encouraging health care providers to communicate more effectively with patients following an adverse event or medical error.
5. USA – the shared treatment decision-making approach between patients with chronic conditions (diabetes) and their clinicians.
|Involved health care staff|
|1. UK, provides information on the evidence concerning a more active role of the clinicians on involving patients into the treatment decision-making.
2. Sweden, The Netherlands, Spain, Italy and Poland – all the healthcare professionals, including: doctors, nurses
3. Spain, physicians involved in the work with patients with multiple co-morbidities
4. US, any medical staff: physicians, administrators, other staff from the healthcare setting. “Researchers have identified another pool of hospital staff members who would be suitable process consultants—those who are looked to within the institution, regardless of title or status, as natural problem solvers and conflict resolvers and who exhibit many of the skills needed during disclosure conversations.” [p. 25, 4].
5. US, healthcare team, mainly clinicians, involved in treatment of chronic diseases.
|Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references|
|1. UK, includes examples of treatment decision making from clinical settings (oncology, internal medicine, others) and builds on a comprehensive model that includes patient and professional participation in the inpatient and outpatient services. The created model is assumed to be available in all settings and in all the patient conditions where this is able to express its preferences and views.
2. Sweden, The Netherlands, Spain, Italy and Poland – patient participation in the handover process between the inpatient setting and the patient’s home/ primary setting.
3. Spain, primary care, where errors in communication with older poly-medicated persons relate with health risks.
4. US, the practice was tested in four hospitals from Pennsylvania, based on the “One reform requirement—that hospitals inform patients about quality problems in their medical care—also creates an opportunity for improved patient safety.
5. US, shared treatment decision-making (STDM) as applied to patients with chronic conditions and their clinicians.
|Summary of evidence for effectiveness, including references|
|Patient involvement to improve patient safety through the communication with the health care professionals is a complex subject, although obvious in healthcare decision making. Literature that aims at proving the importance of the communication process evolved from simply emphasizing the doctor-patient communication (where the degree of patient involvement differentiates based on the paternalistic model, shared decision-making, informed model) to a more complex model focusing on the importance of clinician’s views of their relationship with patients [p. 269, p.276, 1].
“The conceptual framework outlines a variety of aspects of patient involvement in decision-making that clinicians might facilitate. It encourages attention not just to the kind of involvement that can be achieved ‘directly’ in discussion with patients about health care options, but also to the ways in which clinicians might enable patients to engage in the full range of decision-making activities within and outside of consultations and to develop a positive sense of involvement in these activities and with their health care providers.
However, most evidence concerns the inpatient environment, either as the starting point of the treatment and decision-making process or the place where the patients need to be more active. There is also evidence in the handover process, which focus on the importance of involving patients. Moreover, the handover communication should be “clear and unambiguous”, therefore, “a system that ensures them [patients] in a transparent manner” [p. i95, 2] needs to be set.
Although much evidence concerns the inpatient settings, addressing communication problems by involving patient and physician can contribute to avoiding half of “most common of adverse events” [p. 56, 3]. The practice is backed by a study which strongly support that “medication errors represent a threat for the health of older poly-medicated patients with multiple comorbidities” [p. 59, 3]. In this context, the point is involving patients as communication partners to provide physician with information on medication they take.
There is also an important discussion on communication with patients on disclosure of errors and adverse events where effectiveness is required from the healthcare-providers, emphasizing that patients might be involved in claiming their rights because of the perception that “physician was not completely honest” with them [p. 22-24, 4].
– “The model encourages physicians, hospital administrators, and other health care providers to communicate more effectively with patients following an adverse event or medical error, learn from mistakes, respond to the needs and concerns of patients and families after an adverse event, and reach a fair and cost-effective resolution of valid claims.” [p. 23, 4]
Patient involvement requires also a good communication with the professionals
|Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references|
|“The proposed framework is potentially challenging for clinicians who must facilitate patient involvement in decision-making. Not only does it require attention to seven domains of involvement and six activities of decisionmaking, it suggests that clinicians’ success in facilitating patient involvement may depend on their underlying motivation — in the domains of ‘Clinicians feelings about their roles, efforts and contributions relating to decision making’ and ‘Clinicians’ views of their relationships with patients’” [p.275, 1].
Although patient participation in the handover process can be applied in different countries, it is important that its implementation consider the way the healthcare system is organised, “the activity of healthcare professionals and the patient themselves” [p. i95, 2].
The practice can be applied to a more specific group of patients: older polymedicated patients with multiple comorbidities, where communication failure with physicians facilitate medication errors as proved in one study from Spain. The study reveals also that problems are similar at different healthcare levels (and therefore applied at this levels): primary, inpatient and emergency care, altough apparently do not have serious consequences: “The consequences of AE (adverse events, our note) in primary care are less severe than those in other health care settings. Nevertheless, the fact that they have mild consequences is no excuse for attempting to prevent these AE. The same applies to patient errors. Most appear not to have severe consequences. In our study, we also analysed the frequency with which patients attended a hospital or sought medical help as a result of their own mistakes in the self-administration of medicine. The need for emergency care or hospital admission was similar to that seen in studies about medication errors by primary care professionals.” [p. 61-62, 3].
On the other hand, involving patients in communicating errors and adverse events, requires, at first, training and involvement of healthcare professionals that have certain abilities and prove to have good listening skills, no matter their position in the organisation. “The model encourages physicians, hospital administrators, and other health care providers to communicate more effectively with patients following an adverse event or medical error [….]”; “While the study focuses on Pennsylvania, discussions with physicians in other jurisdictions suggest that the challenges and opportunities described here have broad application” [p. 23, 4]. The model also emphasizes on improving the abilities of professionals in order to find the right way to further involve patients in the communication on patient safety and risks.
The involvement of patients as active partners in the treatment decision-making is more obvious and needed in chronic care treatment contexts: “differences
|Summary of available information on feasibility, including references|
|The patient-clinician or practician communication is recognized as a patient safety practice. The novelty of the practice described in this fiche consists of emphasizing the role of patient in the healthcare process, as a communication partner. The literature review for the “Patient involvement to improve patient safety, specifically focusing on the communication in the health care environment as a safety risk” searched for evidence across different settings, patient conditions and topics to communicate to the patients.
“Clinicians who aspire to facilitate patient involvement in decision-making need to look beyond the way they discuss health care options with patients. They should also consider how they might enable patients to engage in the full range of decision-making activities and to develop a positive sense of involvement in these activities and with their clinicians.” [p. 268, 1].For the patients with chronic conditions, “the ongoing partnership is key in choosing initial approaches and in allowing for subsequent revisions.” [p. 31, 5].The approach of patient’s participation in the handover process emphasizes on further improvements in the healthcare organisations, although patients’ participation is meaningful, mostly when the “responsibility for the handover communication is clear
and unambiguous”. [p. i95, 2].
Evidence shows that medication errors occurs in older poly-medicated persons, therefore involving patients in communicating specific information on other drugs they take and other specific information can help in improving the patient safety [p. 56, 3]. Later in the healthcare process, if medical errors occur, their disclosure should pay attention more to the role of professionals when involving patients in the follow-up discussion: “(1) physicians and other health care professionals develop an awareness of the communication skills most likely to be useful during disclosure conversations” [p. 24, 4].
|Existing implementation tools, including references|
|Since the review looked for articles including strong scientific evidence concerning the practice, sometimes the practice is described as an improvement of the relevant applied models, but with less practical testing. For example patient involvement in decision-making should start with the menu of treatment options and focus on the selection between these options: “a broad conceptual framework for patient involvement in decision-making that incorporates the seven domains of patient involvement outlined in Fig. 1 and the six activities of decision-making listed in Box 3” [p. 274-275, 1].
For the Charles et al. approach to shared treatment decision-making (STDM) as applied to patients with chronic conditions and their clinicians, there are 4 phases involved in the process: “(1) establishing an ongoing partnership; (2) information exchange; (3) deliberating on options; and (4) deciding and acting on the decision”. [p. 30, 5].
Concerning the handover process, further implementation tools need to be developed in line with recommendations from the study that showed the limitations of current approaches that rely to a certain degree or at all on the patient’s involvement. .
In order to contribute to patient safety, physicians in contact with patient with multiple co-morbidities need to consider involving patients in communicating routine information, in particular to identify other medicines that patient may be taking. At the same time, “Instruments or written information should be considered to verify in practice what
|Potential for/description of patient involvement in the CRM practice, including references|
|Considering the theme of the practice, the involvement of patient is described in all the selected articles, the degree of participation varying across them.
The complex model of deepening the involvement of patient and professionals in treatment decision–making “acknowledges that patients can be involved not only because of what they say and do to influence a decision, but also by virtue of what they think and feel about their roles, efforts and contributions to decision-making and their relationships with their clinicians.” [p. 268, 1].
Involvement of patients should be handled with care when disclosing medical errors and discussing adverse events, therefore dialogue between patient and healthcare personnel requires previous preparation of those designated to communicate on the matter. [p. 30, 4].Later research shows that patient participation in the handover process is important, but this requires “healthcare organizations to develop a clear and well-considered system of assigning responsibility (including clear communication, our note) for this process” [p. i95, 2]. Further to that, the involvement of older poly-medicated patients in primary care treatment decisions can contribute to reducing the errors in self-administered drugs when communication mistakes are properly addressed by professionals. 
|Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))|
| Vikki A. Entwistle; Ian S. Watt (2006): Patient involvement in treatment decision-making: The case for a broader conceptual framework. Elsevier, Patient Education and Counseling. Abstract available: http://www.ncbi.nlm.nih.gov/pubmed/16875797
 Maria Flink, Gijs Hesselink, Loes Pijnenborg, et al. (2012): The key actor: a qualitative study of patient participation in the handover process in Europe . BMJ Quality and Safety.
 José Joaquín Mira; Domingo Orozco-Beltránc, et al. (2012): Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Family Practice. Abstract available: http://www.ncbi.nlm.nih.gov/pubmed/22904014
 Carol B. Liebman; Chris Stern Hyman (2004): A Mediation Skills Model To
 Victor M. Montori; Amiram Gafni; Cathy Charles (2006): A shared treatment decision-making approach between patients with chronic conditions and their
|Any additional information on the CRM (e.g. implementation barriers and drivers)|
|In the model where patient is involved as a partner in treating chronic diseases that relies much on patient self-management such as diabetes, possible barriers are related to “the current organisation of the healthcare system”, such as: appointment duration that might affect building on the partnership with the healthcare professional, continuity of care, clinical practice guidelines and the quality system that might put clinicians in the situation of providing patients with “desirable” therapies [p. 33, 4].
Patient involvement has limitations when the communication failure intervene in situations that patient cannot control or participate such as the surgical safety. For example, the study performed in Sweden on Surgical Safety Checklist emphasizes that components which often facilitate communication are sometimes neglected, therefore “the concept of risk and the perceived relevance of checklist items should be addressed” for all surgical team members.