Introduction

The insights of consumers of health care on how systems and practices in health care can be changed to improve safety and quality could add to the growing knowledge in this area. Studies investigating adverse events have traditionally been principally undertaken from a medical perspective.1 There have been few attempts to explore the potential of capturing and analysing the experiences of consumers who have themselves experienced an adverse event, and using such data alongside other data sets to improve safety and quality.

For the purpose of this study, there are several terms that require definition:

1. Adverse event - an unintended or unexpected injury or complication caused during a hospital stay. For the purpose of this study, adverse events have been limited to falls, pressure ulcers and other 'minor' events because of the difficulties in recruiting participants who had experienced anything more serious.

2. Consumer - an individual who has received medical attention, care or treatment. A consumer may also be a consumer advocate or representative; however, for the purpose of this study, it is restricted to those individuals directly receiving care as they had experienced the adverse event directly.

These definitions have been derived from feedback received from participants in this study.

Improving safety and quality in healthcare systems is complex, and there have been rapid developments nationally and internationally in the identification and evaluation of strategies to minimise adverse events and to improve reporting systems involving all key stakeholders. Significant work is also emerging on the contribution that consumer involvement can make to identifying and addressing practice and system structures and processes that compromise safety and quality.

Historically, the contribution of consumers relating to investigations of adverse events has been limited. An annotated literature review conducted for the Department of Health and Ageing regarding consumer complaints found that, while using complaints to improve safety and quality was generally perceived as a good idea, the approach tended to individualise grievances and minimise the impact on the organisation, its protocols and procedures.2 This study attempted not only to link intrinsically the responses of participants with definitive recommendations for service improvement, but also to ensure that recommendations could be clearly correlated with an evidence-based approach to practice change.

Several studies have been identified that examined consumers experiences of adverse events.

A multistage, clustered survey using household interviews was conducted, which sought to determine public opinion on the rate and severity of adverse events experienced in hospitals and the perception of safety in hospitals so that predictors of lack of safety could be identified.1 It was concluded that the experience of adverse events negatively impacted on public confidence in hospitals. The consumer-reported adverse event rates in hospitals (7.0%) are similar to that identified using medical record review. Based on estimates from other studies, self-reported claims of adverse events in hospital by consumers appear credible, and should be considered when developing appropriate treatment regimes.

A survey focusing on health consumers' experiences of adverse events was conducted in 2001. The study described the incidence of adverse events, attitudes to participation in medical decision-making and perceptions of safety.3

A 2002 survey was conducted on consumer health complaint experiences in order to encourage the establishment of a Health Complaints Commissioner.4 The study found that most consumers who had an adverse event wanted changes in procedure to stop similar incidents and an apology. It was concluded that many systemic quality improvement opportunities are being lost because consumers are hesitant about complaining.

A study was conducted in the USA to explore consumer perceptions of consumer-provider communication after an actual adverse medical event because prior consumer error studies are rarely based on real situations.5 The study conducted four consumer focus groups using a semistructured guide, and transcripts were analysed using an editing approach to identify themes. Provider communication timeliness and quality were important influences on consumers' responses to adverse events. Confronting an adverse medical event collaboratively helped both consumers and providers address the consumers' emotional, physical and financial trauma, and minimised the anger and frustration commonly experienced. Health organisations, providers, investigators and policy-makers should consider the consumer experience when developing provider training or evaluating processes in consumer resolution.

In the UK, the National Health Service Modernisation Agency reports on the utilisation of 'consumer' perspectives collected through 'discovery interviews' to identify strategies to improve the safety and quality of care provision.6 The underlying principle of discovery interviews is that the area consumers and carers understand best is the impact of their illness or condition upon their lives. Discovery interviews provide an opportunity for consumers to directly tell the story of their illness or condition using a framework (referred to as a 'spine') that guides them through the key stages of their experience.

In Australia, major national investment in consumer involvement has led to a range of approaches that empower consumers and publications, such as '10 Tips for Safer Health Care' produced by The Australian Council for Safety and Quality in Health Care, which aim at engaging consumers in promoting safety and quality.7 Similarly, improvements in reporting systems are providing both health service providers and consumers with information to monitor and improve safety and quality.

However, the focus was generally around complaints procedures and issues surrounding blame, communication following an adverse event and consumers' hesitation about raising issues related to adverse events.

While these studies do address consumer perspectives on various elements of adverse events, they are limited in that they were predominantly survey designs, which limit the responses received from those interviewed.

No attempt has previously been made to generate an open dialogue with consumers to determine their experience of an adverse event and potential strategies to prevent adverse events from recurring.

The project sought to build on the current body of knowledge on safety and quality in the healthcare environment by capturing narrative accounts of consumer's experiences of compromised safety and quality and to evaluate the degree to which this can contribute to quality improvement processes in a large tertiary teaching hospital. At the time this research commenced, there had been a 2% increase in reported adverse events within the organisation in which the study was to be conducted. Of these, 516 had resulted in no harm, 188 had required some form of investigation or treatment and 10 had resulted in an increased length of stay and morbidity. It was therefore deemed timely that such a study should be conducted to determine consumer perceptions of adverse events and potential resolutions to prevent recurrences of such events.

Methodology

This project sought to elicit barriers and enablers of safe, high-quality care as identified by consumers, and positioned consumers as 'possessors' of valuable knowledge related to systems and practices (as they had experienced these directly) rather than the receivers of knowledge and information. The central aim was to develop recommendations for consumer input into quality improvement, generated from the analysis of narrative accounts of their experiences.

The project consisted of four phases:

* Developing consumer-identified quality improvement strategies

* Consumer validation of identified strategies

* Clinician and quality manager's validation of identified strategies

* Quality improvement program

Phase 1: developing consumer-identified quality improvement strategies

Sample

The project sought to conduct discovery interviews with 30 consumers who had experienced an adverse event in a large tertiary teaching hospital (such as a fall, the occurrence of pressure-related ulcer, a hospital acquired infection or medication error). This opportunistic sample was inclusive of both men and women who were over 18 years of age and who had provided informed consent.

Data collection

Data collection involved conducting in-depth discovery interviews with consumers who had experienced an adverse event during their time in hospital. This approach followed the approach developed by the Modernisation Agency. Within this context, discovery interviews are not conducted in the traditional interview style (i.e. questions and answers). Rather, the aim is to identify improvement strategies that emerge from consumers' stories.

An interview 'spine' was developed as a guide for the stories, and laminated cue cards included the words 'admission', 'being on the ward', the specific 'adverse event' (fall, pressure sore, medication error, infection), 'getting treatment', 'getting better' and 'going home/life impact'. The same cards were shown to every consumer interviewed as a guide to them telling their story. The interviews were conducted on the ward.

Data analysis

The interviews were audio-taped and transcribed, and then subjected to thematic analysis using the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) software program.

The steps involved in qualitative data extraction are based on the processes embedded in the JBI-QARI software package. Data extraction involved transferring raw data from the interview using an approach agreed upon and standardised for this specific project. An agreed format is essential to minimise error, provide an historical record of decisions made about the data in terms of the project and to become the data set for extraction and synthesis. The format for data extraction involved the following steps:

* Reading each interview carefully, then re-reading

* Identifying and extracting key points ('analysed data') within the interview

* Entering the analysed data into the findings/conclusions field in JBI-QARI

* Locating the supporting raw data from the interview and either transposing it verbatim or paraphrasing it as an 'illustration'

* Continuing this process for each interview until all key points from all the interviews have been entered into JBI-QARI

Data synthesis

Data synthesis was performed using the JBI-QARI software package. The process of meta-synthesis embodied in JBI-QARI involves the aggregation or synthesis of the analysed data.

The aim of the process is to generate a set of statements that represent aggregation through assembling the analysed data rated according to their quality. Themes are then developed from these data on the basis of similarity in meaning.

The themes are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice.

The JBI-QARI permits the reviewer to exercise some degree of judgement. However, synthesis using JBI-QARI involves both an aggregation of identified themes and the use of interpretive techniques to summarise the findings of the individual interviews into a product of practical value.

The features of content analysis that JBI-QARI draws on include the need to read and re-read the text to identify the meaning of the content, and the formation of statements that accurately describe the content. The features of discourse analysis that JBI-QARI draws on are the steps pursued to achieve confidence in the data being reviewed insofar as its purpose and its focus on serving the best interests of healthcare recipients.

Phase 2: consumer validation of identified strategies

It was important that the results were deemed valid and useful by participants in order to make a meaningful contribution to safety and quality throughout the hospital. The results of the analysis were posted to participants and to the Consumer Advisory Council of the Royal Adelaide Hospital. The Consumer Advisory Council provides advice and feedback to the hospital on key aspects of the operation of the hospital and has undertaken significant work since its inception in 2002 in an endeavour to ensure that consumers are involved in improving healthcare safety. Feedback was used to ensure that only those results that were seen as valid by participants were included in the final results.

Phase 3: clinician and quality manager's validation of identified strategies

It was also important to ensure that health professionals were provided with an opportunity to validate the identified strategies and ensure a truly collaborative approach to safety and quality improvement. The consumer-validated results were therefore presented at a focus group consisting of six quality managers and clinicians for discussion and feedback. This focus group was audio-taped, transcribed and subjected to integrative analysis using the JBI-QARI software program using the same processes and techniques as described for the analysis and synthesis of the discovery interview data. This phase resulted in a report of synthesised results.

Phase 4: quality improvement program

The recommendations from phase 3 were presented to the Safety and Quality Unit, and discussion regarding strategies to integrate them will be discussed and implemented where possible.

This phase of the project is an ongoing collaboration with the Safety and Quality Unit, which will incorporate development of consumer information regarding safety and quality relating to specific interventions and conditions, and also more broadly in relation to general safety in the hospital environment.

Royal Adelaide Hospital has already identified areas of concern, and they are working towards developing strategies for incorporating consumer experiences into their quality improvement processes. This project has informed quality improvement from the perspective of the consumer and has promoted a collaborative approach to change. The enhancement of the understanding of the consumer experience with regard to adverse events in the healthcare environment has been most beneficial. The Royal Adelaide Hospital fosters an environment that encompasses a culture of safety, and is inclusive of all key stakeholders.

Results

Demographic information

Nine men and six women were recruited between the ages of 20 and 88 years. Three consumers had developed pressure ulcers, seven consumers had experienced a fall, two consumers had developed a cannula abscess and three consumers had a combination of adverse events.

Discovery interview data

The discovery interviews were transcribed and data entered into the JBI-QARI for analysis. The use of JBI-QARI for this research was somewhat unconventional, as not all components of the program were utilised. Text that illustrated themes, metaphors or concepts identified in the interviews was entered into the findings component of JBI-QARI. These findings were then assigned to categories and synthesised.

Findings

The key findings of each interview and the illustration to support those findings are presented below.

Finding 1: Changes in strategy and process may help to prevent adverse events.

Illustration: Now what I do is take the bottle with me but bring another one back, so they fixed that up. [the consumer interviewed had identified the cause of his fall - that is, slipping on spilled liquid - and implemented a change to his own behaviour to prevent it from occurring again]

Finding 2: Early discharge may contribute to the occurrence of adverse events.

Illustration: Well, why did they let me go for that two or three weeks when they knew something was wrong with my foot? I should never have been let out of here to start with and then it was my own doctor who told me there were two bugs in there. And the district nurse who was coming around to change the dressing saw all the green stuff in there, too. So I just don't think any of them know what's going on. Well, if they do they're not telling me too much.

Finding 3: Inappropriate use of equipment and insufficient assessment may lead to adverse events.

Illustration: From the shackles [form of restraint] I'd say. That's what I reckon. The bottom was where my heel couldn't move, which is where the pressure sore came from. I can't work out why they didn't put some bandage around or something so you don't get hurt like that. Even if they do come to shackles, there should be something to cover you. As it works now I came in here for oral surgery and I could go out of here with one of my legs gone.

Finding 4: Individual consumer assessment is necessary to avoid adverse events.

Illustration: Oh, yes, yes, I did fall love. What are those bottles you wee in? I was going down to the toilet (they wanted specimens) and I [horizontal ellipsis] tipped half the bottle of wee on the floor and of course slipped on it and bang, down I went.

Finding 5: Assessment to ensure adequate footwear may assist in the prevention of falls.

Illustration:[regarding adequate footwear] No, no I had those things they put on me. Those stocking things.

Finding 6: Consumer concerns and observations may assist with assessment and prevention.

Illustration:[daughter] It really concerned me especially when I saw her walking around without any dressing on and when it didn't burst I didn't even think about septic, but I'm just so glad that it hadn't burst [with the bugs on the floor from high traffic].

Finding 7: Consumer observations can play an important role in assessment and prevention of adverse events.

Illustration: I did [notice the sores]. I knew they were down there, but I can't see them or anything.

Finding 8: Poor footwear may contribute to the occurrence of a fall.

Illustration:[I was wearing] slippers, which is silly too actually. Slippers are no good I don't think inside on pavement floors.

Finding 9: Regular assessment and consumer observation would assist in preventing adverse events.

Illustration: They had been changing the bandages every day and then yesterday I asked if they were going to change them because they hadn't been changed since Friday. When I use the word neglect I don't point it at any particular person, I think it just comes down to not having enough staff on the ward because there isn't enough time in the day or in a shift to do everything that everyone wants.

Finding 10: Regular assessment for pressure ulcers is important to prevent adverse events.

Illustration: I mean, basically what happened is that I was lying in the bed and my feet were really hurting, but I'm not a sook.

Finding 11: Regular assessment of the consumer and their circumstances may prevent adverse events.

Illustration: I had finished my shower and the nurse put a towel on the floor and I wanted to clean my teeth, so I don't know whether the frame got caught up in the towel or my foot slipped on the towel. I've really got no idea what happened, but the towel was the cause of it.

Finding 12: Adverse events may occur when consumers feel neglected.

Illustration: Work cover paid for it so I don't own it, I just get to use it until I don't need it or I pass away. So I think they thought, well he isn't going to make it so we'll just give his wheelchair away.

Finding 13: Consumers knew they were doing the wrong thing, but felt it necessary to take actions regardless.

Illustration: I got off the bed because I had to go to the toilet because the girl that was usually looking after me wasn't here so I decided to get up myself, which wasn't right and I knew it wasn't right because I just couldn't walk by myself.

Finding 14: Prognosis may affect care, which may result in the occurrence of an adverse event.

Illustration: I think they developed in Intensive care because my first recollection when I came up here was the bandages and that was virtually from day dot coming back from intensive care. I think that's pretty poor. A lot of the sisters on this ward have said to me that they never expected me to go home. They expected me to die here in hospital and I don't know if that's the attitude they took from day dot. Well, what's the use in turning him? What's the use in taking him off his heels? And they just left me lying on my back for days and days. And I think that's not very good.

Finding 15: When consumer complaints are ignored, adverse events may result.

Illustration: Oh, I knew it had gotten worse. It wasn't the same, but I kept telling the nurses and they were ignoring me [horizontal ellipsis] There was pain and a lot of puss coming out of it. It was very unpleasant. I wanted them to get it out, but they didn't do it straight away, I was sitting here nearly all morning, they just kept going past me.

Finding 16: When consumers feel neglected, adverse events may occur.

Illustration: Yeah, I noticed it and I showed them but they didn't do anything about it until one nurse particularly, such a brilliant one, she saw it yesterday morning and was on to it like a flash.

Finding 17: Ensuring consumers have adequate information regarding safety is important to prevent adverse events.

Illustration: Yeah, it was my sister I think and her fella, or her husband, were here and I got out of bed and I just, my feet just fell out from underneath me, slipped out from underneath me. [The nurse] should've been here and I got out of bed before she got here, that was all. They told me to stay in bed until they could give me a hand. So it's my blue, I suppose, not theirs.

Finding 18: Inadequate consumer information regarding safety in hospital may lead to adverse events.

Illustration: Yeah [the fall] it was all my fault!! That's what it was, it was all my fault. I was standing up and I was trying to show off a trick [horizontal ellipsis] and it went wrong. I was trying to stand up. Well, obviously I can stand up anyway, but um, my balance isn't quite right. So that's how it happened.

Finding 19: Consumers require information and education to be able to identify when an adverse event may occur.

Illustration: Yeah, I did [notice that it was red], but they know what the hell they're doing.

Finding 20: Poor communication compromised care because different departments were working in contrast with each other.

Illustration: It was only a couple of weeks ago some bloke came in here and told me they were taking me leg off on the Friday, then the next day another bloke came in and said don't take any notice of him because he doesn't know what he's talking about, then I got another doctor come in and say neither of them knew what they were talking about [horizontal ellipsis] So I just stopped everything and said none of you are doing anything until I work out what's going on!! Because they don't talk to each other and they all come up with different stories. It's bullshit!!

Finding 21: When providing consumers with information, it is important to ensure that actions taken will not result in an adverse event.

Illustration: When I was up in Intensive Care they kept telling you to push your back up like that and my heel was rubbing against one of those blankets and that's how it started. That's the only thing I can put it down to. Because the other leg, there's nothing there, just that one heel.

Finding 22: Overbalance when getting out of bed may contribute to falls.

Illustration: I had a visitor and she was on that side of the bed and I got out the other and I was bending to put my slippers on and just fell over. As I said before there was another old lady who did the same thing and I was horrified. Then I went and did the same thing myself!! I bent forward and just went straight forward. I just over balanced.

Finding 23: Poor orientation to surroundings contributed to the fall.

Illustration: The first three days, or the first four days [horizontal ellipsis] I lost my way back to the ward eight times!! Everything looks the same!! It's all white!!

Finding 24: Unstable walking frames or furniture may contribute to falls.

Illustration: Then the other day I was here and I leant on one of those collapsible chairs [walking frame] and I put my hand out to straighten the leg and I hit the ground and fell onto the muscle part of my thumb which increased to double the size and went a bluish navy blue if you can imagine that. In no time at all. The thumb did not break.

Finding 25: An adverse event in hospital may impact on life at home.

Illustration: RDNS have been told so they can come and do my dressings. I've been doing my own bag for the last week, eight days and uh, RDNS will do my heels because I won't be able to do them myself. I haven't got the equipment at home to look after them and I can't see them or know what they need, whether they need lubricating or drying. Before I came in here I could get around, go to the shops or the post office [horizontal ellipsis] [now] I'll give my carers a list and they'll go.

Finding 26: The experience of an adverse event may result in the necessity for ongoing care and impact on life at home.

Illustration: They [district nurse] used to ring before they came. No specific time, they just used to ring and say we'll be there in 15 minutes.

Finding 27: The occurrence of an adverse event in hospital may result in treatment being required following discharge.

Illustration: I could hardly stand the pain. That was the next day. And basically the result of this, I finished up wearing white stockings. It materialised here [in hospital] and now I have to wear stockings.

Finding 28: Adverse events such as falls may cause anxiety.

Illustration: [horizontal ellipsis] now I just have this fear of falling after what happened. That was a rude awakening. Because I went into the bathroom yesterday morning and as soon as I saw that shower chair I had a panic attack. I thought I'm going to be sick, I'm going to pass out, I don't know what I want to do and I said to the nurse, I think I'm having a panic attack. But over what? Having a shower? No, it was the fall.

Categorisation and synthesis of findings

The categorisation phase involves analysing findings and identifying common themes. These common themes, or categories, are further analysed to arrive at synthesised findings. A total of 28 findings were analysed, from which four categories were derived. These categories were further analysed to produce five distinct syntheses. The information below includes a description of the categories used to support the final synthesis of findings.

Synthesis 1 - assessment and prevention

The majority of responses were related to what was perceived as a lack of adequate assessment. Eleven of the 28 identified findings were related to assessment and prevention. Participants raised issues relating to the potential for their own assessment to contribute to a reduction in adverse events (i.e. with regard to pressure ulcers or cannula site infections) providing that they were equipped with sufficient information to do so and that their concerns would be adequately addressed. Participants also felt that thorough evaluation upon admission (including checking footwear and immediate surroundings) and prior to discharge would also be beneficial. These comments resulted in the final synthesis 'assessment and prevention'.

Synthesis 2 - education and communication

Many of the statements made by consumers regarding their adverse event related to communication. Five findings were categorised relating to a sense of neglect and five were categorised relating to poor communication more generally. Whether this was in relation to communication between the consumer and health professional or between health professionals, there was consensus that poor communication contributed to the occurrence of adverse events. Consumers' comments indicated that with sufficient information regarding general safety principles in the hospital during their stay, strategies to prevent them from falling and education regarding the identification of signs of infection and strategies to prevent pressure ulcers, the incidents of adverse events may be significantly reduced. These comments resulted in the final synthesis 'education and communication'.

Synthesis 3 - hospital environment

Several consumers identified the hospital environment as contributing to their adverse event. Three findings were categorised in accordance with hospital environment. This included poor orientation to the ward and their surroundings as well as inadequate and unsafe equipment such as walking frames. It was considered that improving orientation, ensuring that furniture is fixed and that objects are within reach could contribute to reducing the incidence of adverse events. These comments resulted in the final synthesis 'hospital environment'.

Synthesis 4 - life impact

The experience of an adverse event in hospital was identified as having a considerable life impact for consumers. Four findings were categorised relating to the experience of life following an adverse event and one was related to the psychological impact an adverse event may have. Adverse events were attributed with affecting length of stay, psychological factors relating to anxiety about the possibility of another event occurring and concern about managing the effects of the event following discharge (in several cases, RDNS would be required to make visits following discharge). These comments resulted in the final synthesis 'life impact'.

This is the QARI view displaying the syntheses for the review: SIIP.

Focus group data

The focus group audio-tape was transcribed and data entered into JBI-QARI for analysis. Text that illustrated themes, metaphors or concepts identified throughout the focus group was entered into the findings component of JBI-QARI. These findings were then assigned to categories and synthesised.

Findings

The key findings of the focus group and the illustration to support those findings are presented below.

Finding 1: Footwear should be available for purchase by consumers where appropriate.

Illustration: I saw one consumer who had a really good slipper with the Velcro over the top and so it was easy to take off but it was also firm fitting so if we maybe made some of them available for purchase like the hip protectors down the front.

Finding 2: The hospital should not be responsible for footwear unless a recommendation has been made that compromises consumer safety.

Illustration: I think we're going to get ourselves caught in something where we are supplying slippers to every single consumer that comes into the hospital if we make that statement. I think if we put a consumer in TED stockings, then we should ensure that they've got appropriate footwear so they're not walking around in their TED stockings, but I don't necessarily think that we should be providing the footwear for them unless we have made the recommendation that they wear stockings.

Finding 3: Continuous assessment is more effective than discharge planning for preventing adverse events.

Illustration: Well, I guess you can identify [risk of pressure ulcer] through your Braden score at the start. I mean, we're continually assessing for pressure ulcers, so it's something that should be regular anyway.

Finding 4: It is important to assess for risk and take action.

Illustration: If you identify a risk and act to ensure that that risk is reduced, then that still covers all of those things [falls, pressure ulcers, infection].

Finding 5: Processes are already in place to deal with risk of falling.

Illustration: I think to an extent there are things in place already with the falls risk assessment. It is just whether the staff carry them out.

Finding 6: Risk assessment may prevent someone from being discharged with a pressure ulcer.

Illustration: It's your Braden score and your continual assessment of your Braden that is going to prevent someone from being discharged with a pressure area that develops very quickly into a pressure sore. I mean, if they [consumers] are at high risk and are being assessed regularly it is definitely something we should be doing and looking at.

Finding 7: Placement of equipment for the prevention of falls is controversial.

Illustration: The other thing to consider is that it would be great to be able to leave the consumers walking frame right next to their bed, but if we do then we are going to trip over it when we go to give the consumer their tablets or whatever. Yes, if they were at home they would be able to have it close by, but in hospital there are other people that need to be able to get to them.

Finding 8: Placement of equipment may also be an occupational health and safety issue.

Illustration: Most of them [consumers] will just get up and shuffle over to it anyway. The statement is fine, but we have to have some level of oc health and safety for the people who are trying to move in and around those areas as well and that's not just the staff, but the consumers visitors as well.

Finding 9: Audit of non-slip floors should be made a priority.

Illustration: So maybe we should be auditing the non-slip floors and then making a recommendation that we don't use towels.

Finding 10: Education may be necessary in order to encourage cultural change.

Illustration: Because I think that's a cultural thing with nurses as well, putting towels on the floors.

Finding 11: Towels should not be placed on the floors to prevent slipping.

Illustration: No, I agree, I don't think we should be putting towels on the floor. We have non-slip floors in all of our bathrooms. Drying the floor and getting rid of the towel to me is an option, but not leaving the towel on the floor.

Finding 12: Signage should be incorporated into floor tiles because that is where consumers tend to look.

Illustration: Maybe we could put something in the tiles on the floor. Yeah, I like that idea. Have we actually repaired that yellow line that goes around? Because I have seen people who are so focused on that yellow line that they are walking on top of it.

Finding 13: Signage should be appropriate to/considerate of consumer behaviour.

Illustration: That's one of the big things that the Australian Army teach people out in the field is to look up because the man in the tree is going to shoot you as quickly as the man on the ground and no one looks up. It takes quite a long time to get used to, that when you are walking around you look up. So if the army has trouble with that, then trying to teach consumers to look upwards in an environment, which is so totally different to the one they are normally in, is exactly the same.

Finding 14: Consumer awareness should be raised regarding adverse events and safe behaviour in hospital.

Illustration:[development of a 'be safe in hospital' pamphlet for consumers] It's a good idea.

Finding 15: Evidence-based consumer information pamphlets should be made available to consumers where available.

Illustration: I think it is great that they are being developed, it just concerns me that if we had to give them to every single consumer they wouldn't be as effective. It is more a matter of that information being made readily available and that the consumer is aware of it and can access/request it.

Finding 16: Consumer information should also be made available to staff.

Illustration: It would probably also be good to make them available to staff development for when they teach nurses how to insert IV's so that they are made aware of the pamphlet.

Finding 17: Consumers should always be kept informed, but that is not always feasible.

Illustration: I wish we could do that [keep consumers informed] all the time, but if a consumer was cared for in ICU and something happens, then they come down to us, it is still a concern for them because it is their experience, but we've all moved on because so many other things have happened to the consumer since. I'd love to see that happen all the time. I just don't think that it is realistic.

Finding 18: Consumers should be involved in all aspects of their care, but consumer information sheets should be kept to a limit.

Illustration: I think we need to be involving consumers in all levels of their care and I think that involving them in their care and in decisions about their care is important. Now I love consumer information sheets, but we have so many of them and if you gave a consumer information sheets to a consumer on every single thing, they're not going to read them all. So I really think those should be kept for the "big-ticket" items.

Finding 19: There should be a process to ensure that consumers are informed and do not feel anxious about another adverse event occurring.

Illustration: There is actually room on the AIMS form to say whether they [consumers] are aware of this. And that is rarely used. Has the consumer been notified, has the next of kin been notified, has the doctor been notified, has it been documented in the case notes and very rarely would any of them get ticked. So maybe we need to go back and review the AIMS process to ensure that we actually use that check list.

Finding 20: Appropriate and thorough handover of care should be established.

Illustration: Maybe there just needs to be better hand over of care between departments. I know that can be an issue with us sometimes.

Finding 21: Communication between medical specialities is a concern.

Illustration: Is it just common between medical specialities or is it across the board? Because I would have thought that nurses and physios and OT's would work fairly well together [horizontal ellipsis] they tend to care plan very well together.

Categorisation and synthesis of findings

A total of 21 findings were analysed to produce seven categories. These categories were further analysed to produce three distinct syntheses. The information below includes a description of the categories used to support the final synthesis of findings.

Synthesis 1 - appropriate footwear

There was considerable discussion within the focus group regarding the issue of appropriate footwear. Two findings relating to the availability of footwear and the responsibility of provision of footwear were categorised. These comments resulted in the final synthesis 'appropriate footwear'.

Synthesis 2 - audit and assessment

Eleven findings were categorised relating to various aspects of audit and assessment of processes and equipment. These related to continuous assessment and prevention strategies for adverse events, assessment of occupational health and safety issues, and regular audit and assessment of signage and wet areas throughout the hospital. These comments resulted in the final synthesis 'audit and assessment'.

Synthesis 3 - communication

As with consumers who participated in this study, communication was deemed to be of significant importance to health professionals. Eight findings were categorised from the focus group discussion relating to communication. These related to the production and dissemination of evidence-based health information pamphlets for consumers, consumer involvement in care planning and implementation and strategies for improved communication between health professionals. These comments resulted in the final synthesis 'communication'.

This is the QARI view displaying the syntheses for the review: SIIP focus group.

Discussion

The perspectives, experiences and expectations of consumers of health care have increasing potential to contribute to safety and quality initiatives and improving service delivery. Investigations of adverse events usually focus on the actions taken by individuals leading to the occurrence of an adverse event and seldom focus on the perspectives of consumers.

The individual experiences of consumers who had experienced an adverse event identified not only to barriers and enablers of safe, high-quality health care, but also to the potential contribution that consumers may make towards the utilisation of the best available evidence in the clinical environment.

Consumers showed considerable concern regarding consumer assessment in the prevention of adverse events. Responses indicated that care might have been compromised when assessment was not thorough and consistent, and it was recognised that there was a lack of consumer involvement in this process. It may be that consumers have the potential to play an important role in assessment and prevention strategies providing that they are adequately informed of processes and indications for adverse events specific to their condition or situation. If consumers and their families or carers are recognised as active participants in their care and in assessment and prevention strategies, it may be possible to reduce the incidence of adverse events. Involving consumers as valued partners on the consumer care team, and providing them with essential information about their care were identified as key elements in the prevention process.

Language, personality and perception all impact on successful communication and the ability of health professionals to communicate effectively with consumers in their care and in turn with the potential for an adverse event. A lack of adequate information provision was identified as being a key component driving the failure of both consumers and other health professionals in the prevention of adverse events. The necessity for consumers to have information regarding both general safety within the hospital environment and condition-specific information relating to signs of trauma or infection was deemed to be of significant importance. Assumptions and perceptions of the consumer/health professional relationship and the roles and responsibilities of each often contributed to the occurrence of an adverse event. Consumers must have a clear understanding of their responsibility and right to raise their concerns regarding their condition, and health professionals must have a clear understanding of the contribution that consumers may make to their care and in the prevention of adverse events.

A hospital cannot be an effective place of healing unless it is first ensured that the physical environment is safe. For consumers, orientation to their physical surroundings and what is considered to be safe and unsafe behaviour within that environment is critical. Potential environmental issues identified by participants of this study included adequate signage on doors, orientation to the ward and the hospital, ensuring that furniture is stable and that objects such as walking frames are within reach. Policies and practices should be in place to ensure that the hospital environment is safe and that consumers and staff behave in a safe and appropriate manner for the duration of their stay.

Clearly, the condition with which a consumer suffers may result in the requirement of assistance following discharge. However, in several of the cases included in this study, the adverse event experienced by the consumer also influenced life following discharge. The potential life impact for one participant was significant with the adverse event resulting in the possibility of losing a leg as a result of early discharge and an inadequately evaluated pressure area. While this synthesis does not point to specific recommendations for clinical practice change (other than the need to rigorously approach strategies for the prevention of adverse events), it is important to remember that these events can impact on the life of a consumer long after their discharge from hospital.

It is interesting to note that many of the causes for adverse events identified by consumers in this study are congruent with the extant literature. For example, causes of falls were identified as including when moving from one place to another (usually the bathroom), getting out of bed and inappropriate footwear.

The syntheses derived from the results of the focus group discussion with health professionals proved invaluable and complemented the consumer perspectives. Much of the discussion surrounding safety and quality issues raised by consumers resulted in the development of practical solutions. Similarly, education and communication and assessment and prevention are often cited in the literature as contributing to adverse events.

Participants recognised that there was often cause for consumers to be unable to wear appropriate footwear, or in fact anything at all on their feet, but concerns were raised regarding the level of responsibility the hospital should take with regard to the supply of appropriate footwear to consumers. It was deemed inappropriate for the hospital to provide adequate footwear to every consumer, but it was thought that it would be reasonable and feasible to have appropriate footwear available to consumers for purchase and for the hospital to provide (where necessary) footwear only when there had been a recommendation for care made that compromised consumer safety (such as the wearing of TED stockings).

Participants identified regular audit and assessment of all potential risk areas, whether related to continuous assessment of consumers, procedures or equipment, as critical to the prevention of adverse events. Continuous assessment of individual consumers using the Braden Scale for Predicting Pressure Sore Risk or falls risk assessment tools were considered to be a vital and necessary component of care planning for every consumer. However, concern was raised with regard to whether such tools were utilised on a regular basis as part of the core activities of each health professional.

Regular audit and assessment of the hospital environment and procedures was also raised as a point of concern. Participants felt that with the introduction of non-slip flooring to most 'wet areas' in the hospital, the use of towels to prevent slipping was inappropriate. While it was felt that using towels to dry the floor was acceptable, it was suggested that the towel should be removed immediately after use and not left on the floor. It was also suggested that regular audit and assessment should also be conducted regarding signage throughout the hospital and recommendations made to the re-development team, particularly with regard to ward orientation. A suggestion was made to include 'directional' signs within the tiles on the floor as this tended to be where the consumer would focus their attention (particularly those consumers with poor mobility).

Placement of equipment, such as walking frames and chairs, was controversial. Participants were cognisant of the fact that consumers would require furniture and equipment to be within reach. However, they were also mindful that clinicians would also require access to the bedside for care, making placement of furniture and other equipment a potential occupational health and safety risk. It was suggested that this would need regular assessment on an individual consumer basis.

Participants identified communication as being equally challenging as it is beneficial. It was agreed unanimously that consumer education regarding safe practices in the hospital was fundamental to consumer safety, and that information regarding safety issues should be distributed upon admission to hospital. The provision of evidence-based health information was discussed, and there were some reservations regarding information overload and the potential that may have on the effectiveness of such information. However, it was thought that such information would prove useful and could be made readily available to consumers upon request.

Participants recognised the necessity for consumers to be actively involved in their care and in decisions regarding their care, but this was not thought to be without the existence of barriers. Care is often the responsibility of more than one department or clinical area, and involves a significant number of different health professionals. It was agreed that communication should occur frequently and thoroughly regarding adverse events. However, this was not considered to always be feasible when the incident occurred and care was received in another ward or area. It was suggested that thorough handover of consumers and communication between medical specialties could be better facilitated.

As discussed in the extant literature, it is clear that consumer perspectives on adverse events have significant potential to inform service improvement strategies. While the outcomes of the current study were in line with previous work, the open dialogue generated here enable consumer perspectives to be obtained without limiting them in any way. It is felt that this study further strengthens the body of knowledge relating to consumer perspectives on safety and quality improvement strategies.

While these syntheses identified areas where it was felt that service improvements could be made, it is also important to note that much was learned from the discovery interviews that confirmed and valued high-quality current practice. It is important that these aspects are acknowledged and celebrated. Because of the nature of this project, these components of the interviews were not the focus of the syntheses; however, this information was fed back to clinicians at a safety and quality forum.

Limitations

The limitations of this investigation were related to recruitment of participants and terminology. The process of recruiting participants for this research was controversial. It was originally intended that participants would be recruited via the Advanced Incident Management System (AIMS) forms. AIMS is a computerised system for collecting, classifying, analysing, managing and learning about things that go wrong in health care, which allows the collection of information from a wide variety of sources and enables that information relating to incidents may be classified in a consistent way, so that subsequent, detailed analysis is possible. However, upon submitting the proposal to ethics, it was discovered that AIMS is a declared quality-assurance activity under the Health Insurance Act 1973: Part VC, Health Insurance Amendment Act 1992. This legislation provides statutory protection of identified data (e.g. nurse/doctor/consumer's names) collected solely for the purpose of the AIMS process. Passing on the AIMS form, or disclosing identified information contained within a form, to people who are not involved in the AIMS process is considered to be a breach of the Act.

Following a meeting with the Department of Health, it was decided that participants would be recruited via the staff in the hospital. This process also presented difficulties with staff hesitant to contact the research team, feeling that they may be putting themselves or the hospital at risk of litigation. The aims of the project were presented at a Nursing Forum in the hope that this would reassure staff and encourage them to recruit participants. Unfortunately, nursing staff are busy and the demands on them for research projects abundant. The most effective strategy for recruitment was doing ward rounds to ask staff if there had been an adverse event.

Terminology also proved difficult, with participants requiring considerable explanation as to what was meant by an 'adverse' event. Following an interview where a participant described the event as 'unexpected', this term was adopted for the duration of the research. It is important to note that when conducting research with consumers of health care, language can make an enormous difference to the responses given. Using plain English language that is free of jargon is critical in such circumstances.

Conclusions

This project demonstrated the potential of consumers to contribute to meaningful outcomes regarding the prevention of adverse events in hospitals. Involving both service users and service providers in the process of identifying safety and quality issues in clinical practice can strengthen the relevance of the changes being made and assist in establishing priorities for service improvement. Consumers involved in this study identified poor communication, insufficient consumer education, poor assessment and prevention strategies and the clinical environment as contributing to the occurrence of adverse events. The identified concerns resulted in poor consumer outcomes, some of which were significant impacting not only on their hospital stay but their life after hospital also. The health professionals involved in the study concurred with consumers regarding the identified contributing factors and offered some constructive feedback with regard to how such issues may be overcome by facilitating immediate practice change and making recommendations for the future.

Recommendations for practice

The following recommendations are based on the feedback received by both consumers and health professionals and are made with a view to improving consumer care and reducing the incidence of adverse events in hospital:

Assessment and prevention

1. Risk should be assessed for all aspects of care and action taken as determined on an individual basis.

* Towels may be used to dry wet floor, but should not remain on the floor where they may cause a fall

* Consumers who are required to collect urine specimens should not carry the specimen back, but inform staff so they may retrieve it

* A multidisciplinary approach should always be taken regarding pressure ulcers when repositioning consumers or where exercises are recommended for in-bed strategies must be utilised to reduce shearing

2. Footwear should be assessed upon admission to the ward and appropriate footwear made available for purchase where possible (if wearing stockings, socks or slippers with insufficient grip) to minimise the incidence of falls.

3. Adequate decision support systems should be put in place that acknowledge the contribution that consumers can make to the prevention of adverse events.

Education and communication

1. Where possible/feasible following an adverse event, consumers should be adequately informed of what occurred and the processes followed (i.e. if the consumer was unconscious when event occurred).

2. Evidence-based consumer information pamphlets that complement best practice information received by staff should be made available to consumers and they should be encouraged to participate in their care and in the prevention of adverse events.

3. Health professionals should be aware that consumers may feel anxious following an adverse event and should reassure them.

4. Consumer awareness should be raised regarding risk of adverse events and safe behaviour and practices in hospital (i.e. provision of a 'be safe in hospital' pamphlet in their admission pack).

5. When more than one department or clinical area is involved in the care of an individual consumer, there should be adequate communication of care plans to ensure continuity of care and a holistic approach to care.

Hospital environment

1. Equipment should be placed within the reach of consumers or completely out of sight so that they must call for assistance in order to reduce their risk of falling. This should be assessed on an individual basis and the occupational health and safety of staff considered as well as the safety of the consumer and their visitors.

2. Regular audit and assessment (i.e. for wet areas and signage) should be conducted on a regular basis in order to reduce the incidence of adverse events.

* Wet areas should be assessed to ensure they have non-slip floors (towels should not remain on floors after drying)

* Consumer requirements regarding signage should be assessed and placement of 'directional' signs in floor tiling should be considered (e.g. indicating bays and bed numbers)

Recommendations for further research

It is important to note that, while the focus of discovery interviews is not on the number of interviews conducted but on the quality and number of improvements that may be implemented, the results of this study are by no means conclusive, and the numbers of participants recruited were not sufficient to achieve saturation. They do, however, provide a pivotal foundation upon which further investigation may be based.

References