What are Patients ’ Concerns about Medical Errors in an Emergency Department ?

OBJECTIVES
Concerns about medical errors have recently increased. An understanding of how patients conceptualise medical error would help health care providers to allay safety concerns and increase patient satisfaction. The aim of this study was to evaluate patients' worries about medical errors and their relationship with patient characteristics and satisfaction.


METHODS
This descriptive cross-sectional study was done in the Emergency Department (ED) of a university hospital over a one week period in October 2008. A questionnaire was used to assess patients' worries about medical errors and their satisfaction levels both at an initial interview and by telephone 7 days after discharge. Data were gathered and analysed by χ2, t-tests and logistic regression.


RESULTS
Of 638 patients interviewed, 61.6% declared their satisfaction rate as good to excellent; (93 [14.6%] as poor; 152 [23.8%] as fair; 296 [46.4%] as good; 97 [15.2%] as excellent). A total of 48.3% of patients (44.5-52%, with confidence interval 95%) were concerned about the occurrence of at least one medical error. There was a clear relationship between the general satisfaction rate and having at least one concern about a medical error (Chi-square, P <0.001).


CONCLUSION
This study showed that many patients were concerned about medical errors during their emergency care. Due to the stressful situation in EDs, patients' safety and satisfaction could be improved by a better understanding of patient concerns, education of ED staff and an improvement in the patient-doctor relationship.


E
mergency departments (ED) are busy environments.Confrontation with a wide variety of injuries and illnesses causes a very stressful climate both for patients and physicians. 1 There are many causes of the concerns that can ultimately lead to patient dissatisfaction.Overcrowding, the limitations of nurses and resources, the seriousness of illnesses or injuries and the presence of too many patients who require acute inpatient care, can all disturb patients.Regardless of how well trained and experienced the emergency physicians are, they can make mistakes as they are only human. 2 The probability of medical errors is increased by the acute and unpredictable presentations of illness, and by having to work in a busy and overcrowded environment. 3,4he worldwide expansion of medical knowledge through different kinds of media, has led many people to believe that medical care is not totally safe and that they can become victims of medical errors. 5In one study, 75% of patients experienced concerns about medical errors during their hospitalisation. 6In another study 39% of patients were anxious about the occurrence of at least one medical error. 7Unaddressed patients concerns can lead to dissatisfaction, an unwillingness to return to or recommend this hospital to their relatives, noncompliance with medical advice, and an increase in medico-legal claims. 8,9atients expect to be aware when, where and how malpractice issues happen.They also want to know the reasons for the occurrence and ways to prevent errors. 10Studies of the delivery of health care services are producing improved safety suggestions.Some important aspects of improved care are good teamwork, anticipation of unexpected events, improving communication, providing a conducive learning environment, updating drug delivery systems, addressing patient concerns and engaging patients in error prevention. 10,11The unique characteristics of emergency departments make this environment a suitable place to study patient concerns about medical errors.This study was conducted to determine ED patients' concerns about medical errors and their relationship with their general characteristics and satisfaction status.

Methods
This study was a descriptive cross-sectional study, conducted in the ED of Hazrat e Rasoul Akram Hospital in Tehran, Iran, during a 7 day period in October 2008.The ED has an annual intake of 50,000 patients with both medical and surgical complaints.All adult patients who presented to our ED during the study period were included in the study.Patients with a decreased level of consciousness, who were chemically intoxicated, aged <18 years, or those who were unwilling to participate in the survey were excluded from the study.
3][14] Questions covered subjects such as triage performance, quality of care provided, physical environment, nursing and physician behaviour, and the general opinion about the ED experience.The answers were rated on a five point Likert scale: 5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor.Additional information, including age, sex, type of medical insurance, educational level, main physical complaints, time of admission, and length of stay in the ED, were extracted from the patients' files and recorded.During the survey testing phase, in order to tune the questionnaire to our culture, 8 related concerns, which were proposed in the Burroughs, et al. study, were also investigated for 30 patients. 1 They were also asked one open-ended question about their other concerns during their stay in the ED.Based on these patients' views, we then added two items: mistakes by medical students and ED waiting/treatment time.
The same questionnaire was administered in the ED and then again, 7 days after discharge, by telephone interview.For the latter, up to 10 attempts were made to contact each patient.For patients who were admitted to the ward, their follow-up questionnaire was completed at their bedside.In the questionnaire, patients were asked whether they experienced any of the following medical errors during their hospital stay (coded as yes/no): prescription of wrong drugs; operational problem of medical equipment; nursing mistake; physician mistake; medical student mistake; identity mistaken for that of another patient; laboratory test mistakes; improper diagnosis; lengthy waiting/treatment times, and fall from hospital bed (concern that they might fall).Data analysis was performed using the Statistical Package for the Social Sciences (SPSS, Version 14, IBM, Chicago, Illinois, USA) to answer the following main questions: 1) Which medical errors are the greatest patient concerns?2) Is there any correlation between medical errors and patient characteristics?and 3) Do patient concerns affect patient satisfaction?The chi-square test was used for categorical variables, the unpaired t-test for continuous variables and multivariable logistic regression for prediction.The study was approved by the Ethics Committee of the Faculty of Medicine of Tehran University of Medical Sciences.The researchers obtained consent from patients for participation in the study.

Results
A total of 638 (75%) of the 850 patients included in the study completed both the initial questionnaire interview as well as the 7-day follow-up telephone interview which repeated the same questions.Patients' characteristics are summarised in Table 1.A total of 61.6% of patients had a satisfaction rate of good to excellent; (93 [14.6%] poor; 152 [23.8%]   fair; 296 [46.4%] good; 97 [15.2%] excellent).A total of 48.3% of patients (44.5-52%, with confidence interval 95%) were concerned about the occurrence of at least one medical error.Some of them reported more than one.If patients' responses changed between the initial questionnaire and the 7-day follow-up questionnaire, we took into account all of the concerns mentioned by the patient.The percentages of patients' concerns are shown in Figure 1 as: prolonged ED stay (19%); medical student related error (18.7%); errors with equipment malfunction (8.6%); improper diagnosis (7.1%); injury due to fall from hospital bed (5.6%); physician' fault in management (4.5%);identity mistaken for that of another patient (4.4%); laboratory test mistake (2.7%), and nursing mistake (0.6%) We assessed the factors that might have affected patient satisfaction.This revealed that the gender of patients (chi-square, P = 0.141), their educational grade (chi-square, P = 0.110), age (t, P = 0.191), and length of stay in ED (t, P = .404)did not have any significant relationship with patient satisfaction; however, the outcome of patients (discharged, admitted to wards or those who left against medical advice) (chi-square, P <0.001), and having medical insurance (chi-square, P = 0.20) did have a significant relationship with patient satisfaction.
We found, on the one hand, that only four (3.92%) of the 102 patients (16% of the patients interviewed) who left the ED against medical advice (LAMA) were satisfied with their care.This means that near all of these patients were unsatisfied; they maybe went to another medical centre for continued treatment.On the other hand, for patients who were discharged by physicians or admitted to a ward the satisfaction rates were 68.85% and 80.58% respectively.Of the patients who had a university degree, 24.14% were satisfied with their treatment while 18.77% of those without a university degree were satisfied.This difference was not, however, statistically significant (P = 0.110).A total of 52.92% of female patients were satisfied with their treatment.Although they had less concerns than males, this difference was not statistically significant (P = 0.141).
Table 2 shows the relationship between patient characteristics and patient concerns.Females had greater concerns about improper diagnosis, being mistaken for another patient and falling from a hospital bed, while males were worried about nursing mistakes, equipment malfunction and physician error.Patients with university degrees were markedly more worried about physician error, being mistaken for another patient and improper diagnosis, but less worried about equipment malfunction.Older participants were more worried about medical student error, falling from a hospital bed and being mistaken for another patient, but younger patients were more concerned about equipment malfunction and nursing mistakes.Some of the patients left the hospital without completing the diagnosis or treatment process.They were significantly more worried about improper diagnosis and nursing mistakes.
We conducted a multivariate analysis and found that female gender, leaving the ED against medical advice and having a university degree were independently predictive of having at least one concern about a medical error.Also, multivariate analysis demonstrated that having insurance, being discharged or admitted by a physician and having a university degree were independently predictive of high satisfaction [Tables 3 and 4].There was a clear relationship between the general satisfaction rate and having at least one concern about a medical error (chi-square, P <0.001).

Discussion
Most of the time, EDs have too many acutely ill patients.This situation can be highly stressful for physicians, very disturbing for patients and lead to medical error.This study was conducted to evaluate the patient concerns about medical errors during their visit to the ED.In spite of overcrowding in our ED, the majority of patients expressed satisfaction with the medical care they received during their visit although 48.3% of them were concerned about occurrence of one medical error.In the study by Burroughs, 38% of patients experienced error related concerns. 1In other studies, the reported "medical error anxiety" rate was much higher. 11,15e following factors are suggested as the causes of the greatest concern about medical error which ultimately result in more dissatisfaction: severity of illness or pain; uncertain clinical diagnosis; prolonged ED stay; unclear or insufficient    explanation from nursing or physician, and unclear management plan [16][17][18][19][20] In our study, younger patients were more concerned than the older ones.This finding is similar to the Burroughs study. 1 We surmise that the reason for this may be that elderly patients likely have more previous ED experiences and their illness may be less unexpected.In our study, patient concerns were correlated with length of ED stay.However, Thompson et al. reported that opinions regarding perceived waiting time rather than actual waiting time were correlated with patient satisfaction. 21Although the ED length of stay was influenced by factors such as seriousness of illness, overcrowding, and the shortage of ED staff in relation to patient numbers, the probability of medical error occurrence increases with more prolonged ED stays. 1 It has been shown that providing the public with ED waiting time information can reduce lengthy ED waiting times. 22oncerns about falling from a hospital bed were greater in older patients.This may originate from motor or equilibrium problems in this age group.Patient concerns had a direct relationship to educational levels.More educated patient had more complaints and paid more attention to the likelihood of medical errors.Patients who were discharged home were less concerned than the others, both on initial interview and at 7-day follow-up.As patients' management could be influenced by factors such As the severity of their illnesses, it may have biased the patients' level of concern.One common concern was the possibility of errors by medical students.
A possible solution to this concern would be to inform patients about the advanced capability and sophisticated training which medical students receive before they work in clinical wards, and to underline that all student work is supervised by attending physicians.Another way to decrease concerns about student error would be to improve the knowledge and clinical expertise of medical students themselves in order to make them more proficient and self-confident.This is important as two studies found that patients were unwilling to have procedures done by medical students. 23,24orries about medication mistakes have been found to be one of the major and fundamental reasons for patient concern. 25In the current study, the patients were not significantly worried about this error.Most errors were due to diminished attention levels occurring during prescribing, dispensing or administering drugs. 26Collaboration with the clinical pharmacist can reduced harmful medication error. 27here is a significant relationship between the level of patient concerns and their satisfaction.More satisfied patients were less concerned about medical errors.Our results were consistent with previous studies. 1,79][30][31] Although informing patients about the nature and origin of medical errors is valuable, it is not possible in a stressful environments like ED. Regarding the influence of background anxieties on satisfaction in a majority of patients admitted to EDs, 32 a timely recognition of their situation is mandatory.
Although our study has valuable results about types of concerns, our suggestion is to repeat the study in other university hospital EDs, community, or private hospitals to compare the results for patients with different illnesses.Personal characteristics such as psychological, emotional and social factors, which were not considered in this study, could influence the level of patients' concerns.Proper attention to these factors in future studies and also to other clinical situations may further define the factors contributing to patient concerns about medical errors.

Conclusion
Recognition of patient concerns and addressing them in a timely fashion appear to be an effective strategy for improving patient safety and satisfaction.c o n f l i c t o f i n t e r e s t The authors declared no conflict of interest

Figure 1 :
Figure 1: Patients' concerns about medical errors during emergency department visit.

Table 1 :
Demographic data and clinical characteristics of participants Legend: SD = standard deviation; ED = emergency department; LAMA = left against medical advice.

Table 3 :
Multivariate analysis (binary logistic regression) predictive of being concerned about at least one medical error Legend: SE = standard error; CI = confidence interval; LAMA = left against medical advice.

Table 4 :
Multivariate analysis (binary logistic regression) predictive of high satisfaction