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Relationship between complaints and quality of care in New Zealand: A descriptive analysis of complainants and non-complainants following adverse events

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To estimate the proportion and characteristics of patients injured by medical care in New Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability Commissioner ("the Commissioner"). The percentage of injured patients who lodge complaints was estimated by linking the Commissioner's complaints database to records reviewed in the New Zealand Quality of Healthcare Study (NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic differences between complainants and non-complainants. New Zealand public hospitals and the Office of the Commissioner in 1998. Patients who lodged claims with the Commissioner (n = 398) and patients identified by the NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner (n = 847). Adverse events, preventable adverse events, and complaints lodged with the Commissioner. Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas (OR 0.3, 95% CI 0.2 to 0.6). Most medical injuries never trigger a complaint to the Commissioner. Among complaints that are brought, severe and preventable injuries are common, offering a potentially valuable "window" on serious threats to patient safety. The relatively low propensity to complain among patients who are elderly, socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation of complaints processes.
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ORIGINAL ARTICLE
Relationship between complaints and quality of care in New
Zealand: a descriptive analysis of complainants and non-
complainants following adverse events
M M Bismark, T A Brennan, R J Paterson, P B Davis, D M Studdert
...............................................................................................................................
See end of article for
authors’ affiliations
.......................
Correspondence to:
Dr D M Studdert, Harvard
School of Public Health,
Boston, Massachusetts
02115, USA; studdert@
hsph.harvard.edu
Accepted for publication
17 October 2005
.......................
Qual Saf Health Care 2006;15:17–22. doi: 10.1136/qshc.2005.015743
Objectives: To estimate the proportion and characteristics of patients injured by medical care in New
Zealand public hospitals who complain to an independent health ombudsman, the Health and Disability
Commissioner (‘‘the Commissioner’’).
Design: The percentage of injured patients who lodge complaints was estimated by linking the
Commissioner’s complaints database to records reviewed in the New Zealand Quality of Healthcare Study
(NZQHS). Bivariate and multivariate analyses investigated sociodemographic and socioeconomic
differences between complainants and non-complainants.
Setting: New Zealand public hospitals and the Office of the Commissioner in 1998.
Population: Patients who lodged claims with the Commissioner (n = 398) and patients identified by the
NZQHS as having suffered an adverse event who did not lodge a complaint with the Commissioner
(n = 847).
Main outcome measures: Adverse events, preventable adverse events, and complaints lodged with the
Commissioner.
Results: Among adverse events identified by the NZQHS, 0.4% (3/850) resulted in complaints; among
serious, preventable adverse events 4% (2/48) resulted in complaints. The propensity of injured patients to
complain increased steeply with the severity of the injury: odds of complaint were 11 times greater after
serious permanent injuries than after temporary injuries, and 18 times greater after deaths. Odds of
complaining were significantly lower for patients who were elderly (odds ratio (OR) 0.2, 95% confidence
interval (CI) 0.1 to 0.4), of Pacific ethnicity (OR 0.3, 95% CI 0.1 to 0.9), or lived in the most deprived areas
(OR 0.3, 95% CI 0.2 to 0.6).
Conclusion: Most medical injuries never trigger a complaint to the Commissioner. Among complaints that
are brought, severe and preventable injuries are common, offering a potentially valuable ‘‘window’’ on
serious threats to patient safety. The relatively low propensity to complain among patients who are elderly,
socioeconomically deprived, or of Pacific ethnicity suggests troubling disparities in access to and utilisation
of complaints processes.
T
here is growing international interest in harnessing
patient dissatisfaction and complaints to address pro-
blems with quality in health care.
1
The value of
complaints as a marker of threats to patient safety depends
on the answers to several questions. Do complaints track
injuries, or are they prompted by more subjective concerns?
Are complaints the ‘‘tip of the iceberg’’ in terms of quality of
care problems and, if so, how representative are they of
broader quality problems? The longstanding obstacle to
addressing these questions is methodological in nature and
concerns the elusiveness of an appropriate metric against
which to measure the prevalence and reasonableness of
complaints.
In New Zealand, injury compensation and complaints
against healthcare professionals are dealt with in distinct
settings. An innovative accident compensation system
compensates injured patients on a ‘‘no fault’’ basis. An
independent health ombudsman, the Health and Disability
Commissioner (‘‘the Commissioner’’), has statutory respon-
sibility for resolving patient complaints about quality of care,
acts as a gatekeeper to disciplinary proceedings, and strives to
use complaints as a catalyst for improving patient safety.
2–4
In this study we linked information on quality of care
complaints lodged with the Commissioner with adverse event
data gathered in the New Zealand Quality of Healthcare
Study (NZQHS). Together, these two datasets permit
estimation of how frequently adverse events led to com-
plaints, and a description of the characteristics of patients
who did and did not complain to the Commissioner.
METHODS
The Wellington Ethics Committee and the Harvard
Institutional Review Board approved the study.
Baseline data on a random sample of patients who had
experienced adverse events came from the NZQHS. As
previously described,
5
NZQHS used a two stage sampling
process to develop a representative sample of 6579 medical
records of patients discharged from publicly funded acute
care hospitals in 1998, excluding psychiatric and same day
discharges. Trained reviewers assessed each episode of care
for the presence of an adverse event and, when an adverse
event was detected, rendered a judgment on whether it was
preventable. Following previous research in the United
States,
67
adverse events were defined as unintended injuries
caused by healthcare management, rather than the under-
lying disease process, that resulted in disability. The study
included all adverse events detected during or responsible for
the index admission, as well as those occurring during the
index admission that were detected on a subsequent
17
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admission. Serious adverse events were those which caused
death or permanent disability.
The Commissioner provided data on all complaints
received by his office that were associated with a public
hospital admission in 1998 (n = 398). To determine which of
these complaints involved adverse events and preventable
adverse events, an investigator with medicolegal expertise
(MMB) reviewed the relevant administrative information
using the NZQHS process of structured implicit review. A
second investigator (TAB), also a medicolegal expert,
independently reviewed a random subsample of 98 com-
plaints, a quarter of the sample. Inter-rater reliability for
determination of whether an adverse event had occurred was
high (k = 0.84); reliability for preventability judgment was
moderate (k = 0.50), although slightly higher than previous
estimates of reliability for preventability determinations.
78
We matched the NZQHS records to complaints probabil-
istically using national hospital number, date of birth, sex,
and date of injury. Clinical data from the medical record
review was then compared with claims data to confirm that
the NZQHS patient and complainant was the same person
and that the complaint related to the same episode of care.
Two investigators (MB, DS) reviewed potential matches and
reached consensus on whether sufficient information existed
to confirm a match with a high degree of certainty. Among 18
candidate matches, nine were determined not to be matches
and two were excluded on the grounds that there was
insufficient information to confirm a match.
The analyses are descriptive. We compared characteristics
of patients who lodged complaints with the Commissioner
after experiencing an adverse event (‘‘complainants’’) with
characteristics of patients from the NZQHS who experienced
an adverse event and did not file complaints (‘‘non-
complainants’’). Matched cases—that is, patients from the
NZQHS sample whose care involved an adverse event and
who subsequently complained about that instance of care—
were classified as complainants. Figure 1 shows the deriva-
tion of the two populations which were combined for the
multivariate analysis.
Data were analysed using the SAS 9.0 statistical software
package (Cary, NC, USA) Stata 8.0/SE (Stata Corp, College
Station, Texas). We used t tests and x
2
tests to conduct
bivariate comparisons of the characteristics of complainants
and non-complainants. We investigated predictors of failure
to complain despite having experienced an adverse event
using multivariate logistic regression. The dependent variable
in the regression analysis distinguished complainants from
non-complainants. The independent variables were sex,
ethnicity (Maori, Pacific, Non-Maori/non-Pacific), patient
age (,1 year, 1–17 years, 18–44 years, 45–64 years,
>65 years), disability due to adverse event (temporary,
permanent with ,50% impairment, permanent with .50%
impairment, death), and whether or not the event was
preventable. An additional covariate provided a measure of
the patient’s socioeconomic status using the New Zealand
Index of Deprivation Score.
910
This index, based on mesh
blocks, combines nine census variables reflecting aspects of
material and social deprivation; following previous studies,
11
index scores were separated into quintiles for analysis.
To account for the stratified two stage cluster sampling
design in the NZQHS,
12
the bivariate and multivariate
analyses were weighted. The weighting had negligible effects
on our estimates.
RESULTS
The Commissioner received 398 complaints related to care
delivered in public hospitals in 1998, 254 of which (64%)
related to an episode of care in which the patient had
experienced an adverse event. For 51% of the complaints the
adverse event was judged to be preventable. The NZQHS
review identified 850 adverse events, as previously reported,
5
of which 315 were preventable, 124 were serious, and 48 were
both serious and preventable.
Patients themselves instigated 105 (41%) of the 254
complaints involving adverse events (fig 2). Third party
complaints were commonly laid by family members, primar-
ily the patient’s child (17%), parent (16%), or spouse (13%).
A total of 79% (313/398) of complaint letters and 75% (191/
254) of the adverse event complaint letters expressed concern
about a health professional’s attitude or communication
either during the index admission or after the adverse event.
There were seven matches between the complaint sample
and the full NZQHS sample (n = 6579). NZQHS reviewers
judged three of these matches to involve adverse events (one
preventable death, one preventable permanent disability, and
one unpreventable temporary injury); the rest did not involve
adverse events. (Besides injuries, the Commissioner also has
jurisdiction to hear complaints relating to informed consent,
discrimination, and a variety of other bases of dissatisfaction
with care.) Hence, 0.4% (3/850) of the patients in the NZQHS
sample who experienced adverse events complained. Among
NZQHS patients judged to have experienced adverse events
that were serious and preventable, 4% (2/48) complained.
New Zealand Quality of
Healthcare Study reviewed
records of 6579 patients
(approximately 1% of
admissions)
Health and Disability
Commissioner received
398 complaints
(national database)
699095 patients admitted to New Zealand public hospitals
in 1998
847 sampled patients suffered an adverse event but did not complain
850 adverse
events
3 matches
254 complaints
following
adverse events
Figure 1 Identification of injured complainants and non-complainants.
Patient
41%
Spouse
13%
Other
5%
ACC
4%
Healthcare
provider
4%
Child
17%
Parent
16%
Figure 2 Relationship to injured patient of person writing letter of
complaint (n = 254).
18 Bismark, Brennan, Paterson, et al
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Box 1 provides case studies of three patients. The first
patient complained following an adverse event. The second
patient suffered an adverse event and did not complain. The
third patient complained but, because the poor outcome he
experienced was attributable to the condition for which care
was sought rather than the medical care itself, it was not an
adverse event.
Table 1 shows the characteristics of the patients in the full
NZQHS sample, the subset of patients who experienced
adverse events (except for the three who complained), and
the complainants who experienced adverse events. The
average age of the complainants was 47 years and 59% were
female. Among complainants for whom ethnicity data were
available, 14% were Maori and 3% were Pacific. In general,
complainants’ injuries involved were quite severe, with 31%
resulting in permanent injury and 28% in death. Most of the
injuries (79%) were preventable. 44% (110/254) of com-
plaints involved an injury that was both permanent and
preventable.
Bivariate analyses showed several significant differences
between injured complainants and injured non-complainants
(table 1). Compared with complainants, non-complainants
were significantly older (52 v 47 years, p = 0.003) and more
likely to live in deprived socioeconomic areas. Complainants,
on the other hand, were significantly more likely to have
sustained injuries that led to permanent disability or death,
and preventable adverse events were twice as common in this
group (79% v 37%, p,0.001).
These differences persisted in multivariate comparisons of
the complainants and non-complainants (table 2). Injury
severity was a strong predictor of complaining, with odds of
complaining increasing with injury severity. Compared to
patients with temporary disability, the odds of complaining
for patients with a permanent disability resulting in .50%
impairment were 11.4 times greater (95% CI 5.9 to 22.1), and
for patients who died they were 17.9 times greater (95% CI
9.3 to 34.2). There was also a strong independent correlation
between preventability and odds of complaining (odds ratio
(OR) 7.6, 95% confidence interval (CI) 5.0 to 11.6).
In addition, several sociodemographic factors were asso-
ciated with propensity to complain after an adverse event.
Odds of complaining for patients in the most deprived
quintiles were one third those for patients in the most
privileged quintile (OR 0.3, 95% CI 0.2 to 0.6). Elderly
patients were significantly less likely than their younger
counterparts to complain following an adverse event (OR 0.2,
95% CI 0.1 to 0.4). Odds of complaining for patients of Pacific
ethnicity were lower than for non-Maori/non-Pacific patients
(OR 0.3, 95% CI 0.1 to 0.9). The difference was not
statistically significant for Maori patients, perhaps because
of the relatively small numbers in this category.
DISCUSSION
Principal findings
This study is the first to match epidemiological data on
medical injuries to complaints about quality of care lodged
with a national health ombudsman. Three findings are
noteworthy. Firstly, while the right to an appropriate
standard of care is only one of 10 patient rights enforced by
the Commissioner, most complaints involved an adverse
event, often a serious one. Secondly, our results suggest that
approximately one in 200 injured patients complain about
their care to the Commissioner. Among patients who
experience injuries that are both serious and preventable,
one in 25 complain. Thirdly, the ‘‘under-complaining’’
phenomenon was not spread uniformly across the patient
population: elderly patients and socioeconomically disadvan-
taged patients were especially unlikely to complain despite
having suffered an injury, and propensity to complain
increased steeply with the severity of the injury sustained.
Legitimacy of complaints
Although New Zealand doctors appear to support the use of
complaints as a quality assurance tool, concerns abound in
the medical community about the prevalence and reason-
ableness of many complaints brought before the
Commissioner.
13–15
The 2001 survey by Cunningham and
colleagues
13
of doctors’ attitudes about complaints found
general support for a forum for hearing and investigating
complaints, but considerable scepticism about the legitimacy
of complaints actually lodged with the Commissioner. Only
one in 10 doctors agreed with the statement that most
complaints were warranted, and half disagreed with the
statement that most complaints are about errors and actual
wrongdoing.
Box 1 Case studies of injured patients who did
and did not complain
Adverse event with no subsequent complaint
Mrs A, an elderly woman with a history of hyperthyroidism,
asthma, left ventricular failure, hypertension, and gastro-
oesophageal reflux disorder was admitted to hospital with
dizziness and vomiting. She was dehydrated with low
sodium (113 mEq/l, normal range 135–145). Her list of
13 medications prescribed by her general practitioner
included frusemide 80 mg a day and spironolactone
100 mg twice a day. She was diagnosed with hyponatrae-
mia secondary to an excessive dose of diuretics. She was
rehydrated and discharged 8 days later on a reduced
frusemide dose of 40 mg/day. Mrs A did not complain.
Complaint following adverse event
Mr D, a middle aged farmer, sustained a penetrating injury
to his right eye while cutting firewood. As a result of this
injury Mr D suffered a detached retina. He was referred to an
ophthalmologist who offered to reattach the retina using an
operation he had recently learned in the United Kingdom.
The scrub nurse was unfamiliar with the proposed operation
which involved the use of diluted SF6 gas. The theatre
supervisor was on a meal break because the operating
schedule was running late. Due to a breakdown in
communication between the nurse and the surgeon, the gas
was not diluted and 100% gas was administered to Mr D’s
eye, resulting in total blindness in that eye. He is no longer
able to run his farm due to the loss of depth perception. Mr
D’s complaint was upheld and his claim for no-fault
compensation was accepted.
Complaint with no adverse event
Mr N, a young man, was admitted to hospital with a severe
crush injury to his right middle finger. A senior orthopaedic
registrar with extensive plastic surgery experience assessed
Mr N and discussed the case with his consultant. They agreed
that it would be appropriate for the registrar to attempt to
preserve Mr N’s fingertip. The registrar stabilised the soft
tissue with loose sutures and administered an antithrombotic
prophylactic, dextran, to try to prevent thrombosis of the
artery. Another orthopaedic registrar, who had not been
involved with Mr N’s initial care, told Mr N that crush injuries
should never be sutured, causing him considerable anxiety.
Following discharge, the hospital tried to arrange a follow up
appointment for Mr N but he insisted on going on holiday to
a remote region of New Zealand and did not contact a
general practitioner as had been agreed. His fingertip
became infected and later required partial amputation. The
Commissioner found that Mr N had received an appropriate
standard of care.
Relationship between complaints and quality of care 19
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The second of these opinions is partially correct as a matter
of law. The Commissioner’s obligations extend beyond classic
violations of quality. New Zealand law sets forth a variety of
other rights, including rights to be treated with respect and to
be free from discrimination or financial exploitation.
Perceived breaches of all such rights are legitimate bases
for complaint.
16
Nonetheless, our analysis suggests that doctors’ attitudes
about the reasonableness of complaints are at odds with
reality, at least among the subset of complaints related to
public hospital care. Nearly two thirds of the complainants in
the study sample had experienced adverse events, of which
79% were preventable and 60% involved permanent injury or
death; 93% of the adverse events were either preventable or
serious injuries.
It is incorrect to interpret these results as evidence that
complaints are usually triggered by doctors’ wrongdoing. The
causes of adverse events in medicine are often multifactorial,
involving a complex interplay between individual and system
factors. On the other hand, the prevalence of adverse events—
especially preventable and serious ones—refutes the notion
that most complaints over quality of care are groundless.
Table 1 Characteristics of all patients, non-complainants, and complainants
All patients in
NZQHS, n (%)
(n = 6579)
Injured non-
complainants, n (%)
(n = 847)
HDC complainants
n (%)
(n = 254) p valueÀ
Sex 0.41
Male 2970 (45) 379 (45) 105 (41)
Mean age (years) 42.6 52.0 46.6 0.003
Ethnicity* 0.15
Non-Maori/non-Pacific 5131 (80) 661 (80) 160 (85)
Maori 1013 (16) 135 (16) 26 (14)
Pacific 240 (4) 32 (4) 3 (3)
Deprivation quintile ,0.001
1 (least deprived) 824 (13) 96 (11) 47 (20)
2 907 (14) 128 (15) 57 (24)
3 1354 (21) 184 (22) 46 (19)
4 1583 (24) 205 (24) 4 9 (21)
5 (most deprived) 1834 (28) 227 (27) 38 (16)
Disability ,0.001
Temporary 685 (85) 105 (41)
Permanent ,50% 66 (8) 48 (19)
Permanent .50% 19 (2) 30 (12)
Death 37 (5) 71 (28)
Preventability ,0.001
Preventable 313 (37) 201 (79)
HDC, Health and Disability Commissioner.
*Percentages were calculated using non-missing values as denominators. Ethnicity data were missing for 19 non-complainants (2.3%) and 65 complainants
(25.6%); deprivation scores were missing for seven non-complainants (0.8%) and 17 complainants (6.7%); disability information was missing for 40 non-
complaints (4.7%) and one complainant (0.4%).
p values were calculated for the difference between complainants and non-complainants using t test or x
2
test as appropriate. Hospitals were weighted to account
for NZQHS cluster sampling methodology.
Table 2 Multivariate odds of complaint among patients who experienced an adverse
event
Odds of complaint
(n = 1101) 95% CI p value
Sex
Male 0.75 0.49 to 1.12 0.16
Age (years)
Infant (0–1) 1.06 0.50 to 2.22 0.9
1–17 0.52 0.25 to 1.09 0.08
18–44 1 (ref)
45–64 0.55 0.33 to 0.92 0.02
>65 0.24 0.14 to 0.40 ,0.001
Ethnicity
Non-Maori/non-Pacific 1 (ref)
Maori 0.78 0.45 to 1.36 0.4
Pacific 0.30 0.10 to 0.91 0.03
Deprivation quintile
1 (least deprived) 1 (ref)
2 0.77 0.42 to 1.41 0.4
3 0.47 0.24 to 0.92 0.03
4 0.69 0.37 to 1.28 0.2
5 (most deprived) 0.32 0.16 to 0.63 0.001
Disability
Temporary 1 (ref)
Permanent ,50% 5.88 3.47 to 9.97 ,0.001
Permanent .50% 11.43 5.91 to 22.10 ,0.001
Death 17.86 9.31 to 34.24 ,0.001
Preventability
Preventable 7.60 4.98 to 11.60 ,0.001
20 Bismark, Brennan, Paterson, et al
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Complaint rates
Complaint rates were low. The finding that only 0.4% of
adverse events and 4% of serious preventable adverse events
triggered complaints is consistent with crude estimates of
0.3% (254/85 000) and 2.3% (110/4800) obtained using the
number of complaints as the numerator and an extrapolation
of adverse event rates to the national level as the denomi-
nator.
In an earlier analysis of the same survey data, Cunningham
and colleagues
17
found that one in three doctors had
experienced a complaint at some time in their career; the
study estimated a complaint rate of 5.7% per doctor per year
and used these data to conclude that there was a ‘‘high
incidence’’ of complaints. From the perspective of busy
practitioners, this may be so. But from a health policy
perspective, the prevalence of poor quality care rather than
the number of physicians is the appropriate baseline against
which to measure complaint frequency. Using this metric, we
reach the opposite conclusion: complaints are rare in the
sense that the vast majority of preventable adverse events
never trigger one.
Why are complaint rates so low? Felstiner and colleagues’
conceptualisation of the evolution of disputes through a
process of ‘‘naming, blaming, and claiming’’ helps organise
the most likely explanations.
18
Firstly, many patients may not
be aware that they have sustained an injury from medical
care. Disentangling medical injury from the progression of
underlying illness is not straightforward, especially in the
inpatient setting where that illness may be severe.
Secondly, patients may recognise their injury but be
unaware of the Commissioner’s services, or unwilling to
commit the time and energy needed to take action. In theory,
the complaints process should pose few barriers—patients
can lodge a complaint by writing a letter or by making a free
phone call (0800 11 22 33); a lawyer’s assistance is not
required. However, in perception or reality, it may not be
straightforward for some aggrieved patients. The complaints
process has been described as ‘‘confusing, cumbersome,
difficult to access, and costly, both financially and emotion-
ally.’’
19
Moreover, health professionals are provided with a
copy of the letter of the complaint, including the patient’s
name, so some patients may hold back out of concern that
such action will bring tension into their relationship with
their doctor.
Thirdly, despite both recognising their injury and under-
standing the complaint option, some patients may simply
adopt the attitude that ‘‘what’s done can’t be undone’’, put
the event down to bad luck, and move on. Alternatively, they
may elect to take action, but not with the Commissioner.
Several other options are available to injured patients seeking
redress or accountability following an adverse event.
Monetary compensation is available through the national
no-fault compensation scheme. Patients seeking an apology,
an explanation, or system change to protect others from
suffering a similar harm can have those interests met by
bringing their concerns directly to the attention of their
healthcare provider by using free independent patient
advocacy services, or by lodging a complaint with the
hospital.
Disparities in use of complaints
A study by Tapper and colleagues
20
of complaints against
surgeons found that they were more likely to be brought by
women and patients in older age groups. Again, analyses of
complaints that do not calibrate their frequency to the
underlying rate and patterns of injury can be misleading.
Women and the elderly are leading users of the healthcare
system;
21
they are also over-represented among injured
patients.
5
Calibrating complaints to baseline data on injury,
we found no sex differences in complaint behaviour. Elderly
patients, on the other hand, were one quarter as likely as
their younger counterparts to complain following an adverse
event.
Similarly, socioeconomic disparities in complaint beha-
viour are not readily apparent from a discrete analysis of
complaint data. The incidence of complainants is fairly evenly
distributed across the five deprivation quintiles, but multi-
variate regression analysis controlling for the presence and
severity of injury showed that patients from the most
socioeconomically deprived areas were significantly less likely
to complain. These results echo studies of malpractice
litigation in the United States in which both old age
22 23
and lower socioeconomic status
23 24
have been correlated with
lower propensity to sue.
Severity of injury
The strong relationship we identified between severity of
injury and propensity to take legal action is also consistent
with findings from medicolegal research from the United
States.
23 24
Although the Commissioner’s complaint processes
attract only a small proportion of adverse events, the odds
that an injury will materialise as a complaint increase steeply
with severity of the injury; the odds are also substantially
greater if the injury is preventable. There is thus a clear
‘‘bias’’ in the severity and types of injuries that come before
the Commissioner. Complaints data should not be construed
as representative of general patterns of medical injury. On the
other hand, the skew towards serious and preventable events
is precisely what policymakers might hope for from a system
whose goals are to protect consumers from the most serious
safety hazards and identify opportunities for quality improve-
ment.
Limitations of study
Our study has several limitations. Firstly, complaints relating
to episodes of care in 1998 may have been (or might be)
lodged later than 30 June 2004, the date our complaints
sample was drawn, although this is unlikely because virtually
all complaints are filed within 2 years of the date of the
alleged injury (mean 10 months, median 5 months). The
5.5 year window for complaints that we allowed is therefore
conservative.
Secondly, estimating adverse event rates through medical
record review has recognised limitations.
25 26
In our review of
complaint files, inter-reviewer agreement on the prevent-
ability judgment was only fair. To the extent that complaints
were judged not to involve preventable adverse events and
they did, our regression analysis will underestimate the
predictive value of preventability in complaining.
Thirdly, several of the other variables used in our analyses
were suboptimal. Ethnicity data were missing for one quarter
of complainants, and misclassification of ethnicity is a
recognised problem.
27
The use by the New Zealand Index of
Deprivation of small area-based measures to assign socio-
economic characteristics at the individual level creates the
potential for measurement error.
10
The direction and magni-
tude of potential biases stemming from these data limitations
are unknown, but we know of no reason why they would
differ systematically between complainants and non-com-
plainants and thus affect the results of our analyses.
Conclusion
Given the absence of tort remedies and the availability of a
free independent complaints mechanism, it might be
expected that patients in New Zealand would frequently
lodge complaints following adverse events. Indeed, some
physicians in New Zealand feel under siege by complaints
processes and the medicolegal environment has been
Relationship between complaints and quality of care 21
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described as one of the ‘‘most hostile’’ in the world.
28
Yet
when complaints to the Commissioner are set against the
underlying rate of injury, it becomes apparent that they
represent only the tip of an iceberg of adverse events. That tip
misrepresents what is beneath the surface in two important
ways. Firstly, the relatively low propensity to complain
among patients who are elderly, socioeconomically deprived,
or of Pacific ethnicity suggests troubling disparities in access
to and utilisation of complaints processes. Further research is
required to better understand and address these disparities.
Secondly, the probability of a complaint increases steeply
with severity of injury, and preventable events are much
more likely to lead to a complaint than unpreventable ones.
In this regard, complaints offer a valuable portal for
observing serious threats to patient safety and may facilitate
efforts to improve quality.
ACKNOWLEDGEMENTS
The authors thank Jean-Marie Berthelot and Roy Lay-Yee for their
expert statistical assistance. Elana Curtis offered valuable comments
on the manuscript.
Authors’ affiliations
.....................
M M Bismark, T A Brennan, D M Studdert, Harvard School of Public
Health, Boston, Massachusetts 02115, USA
R J Paterson, Health and Disability Commissioner, P O Box 1791,
Auckland, New Zealand
P B Davis, Department of Sociology, The University of Auckland, Private
Bag 92019, Auckland, New Zealand
Funding for this study was provided by the Commonwealth Fund, an
independent non-profit organization based in New York City. The
authors’ work was independent of the funders.
Competing interests: none.
M M Bismark was a Harkness Fellow in Healthcare Policy in 2004–5.
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For further information please go to: www.quality.bmjpg.com
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... Research has shown that the rates of patient complaints are higher among certain specialties and health professional demographics, with older male surgeons featuring highly in many complaint datasets [5,6]. Likewise, there is growing evidence that some sociodemographic characteristics of patients are associated with a higher risk of complaints [4,[6][7][8][9][10][11]. Anecdotally, when talking about dissatisfaction with healthcare, practitioners sometimes point to their experience with 'difficult patients' although this notion might deserve renaming to 'difficult clinician-patient relationships' [12]. ...
... Research has shown that the rates of patient complaints are higher among certain specialties and health professional demographics, with older male surgeons featuring highly in many complaint datasets [5,6]. Likewise, there is growing evidence that some sociodemographic characteristics of patients are associated with a higher risk of complaints [4,[6][7][8][9][10][11]. Anecdotally, when talking about dissatisfaction with healthcare, practitioners sometimes point to their experience with 'difficult patients' although this notion might deserve renaming to 'difficult clinician-patient relationships' [12]. ...
... An increasing number of studies have demonstrated that some patient socio-demographic characteristics may predict a higher risk of complaints [4,[6][7][8][9][10][11]. Besides, the idea that encounters with some groups of patients, including those with 'mistrustful behavior' , can be particularly challenging appears in the literature [12,[25][26][27][28]. ...
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Background: There is increasing evidence that satisfaction with healthcare and complaint rates vary with patients' socio-demographic characteristics. Likewise, patient personality might influence the perception of health care; however, empirical research has been scarce. The aim of this study was to investigate associations between health care user personality and satisfaction with care and urge to complain. Methods: This study is a randomized survey among Danish men aged 45 to 70 years (N = 6,756; 30% response rate) with hypothetical vignettes illustrating different courses of healthcare. Assuming they received the care described in vignettes, participants rated their satisfaction and wish to complain on a five-point Likert scale. Information on personality characteristics was obtained through self-reports using the standardized Big Five Inventory-10 (BFI-10). Results: In multivariate analyses, we found respondents with higher scores on the agreeableness dimension expressing greater satisfaction with care (Likert difference 0.06, 95% CI 0.04 to 0.07; p < 0.001) and decreased wish to complain (-0.07, 95% CI -0.08 to -0.05; p < 0.001) while high neuroticism scores were associated with less satisfaction (-0.02, 95% CI -0.03 to -0.00, p = 0.012) and an increased wish to complain about healthcare (0.04, 95% CI 0.03 to 0.06, p < 0.001). Interaction analyses could demonstrate no statistically significant interaction between the level of patient involvement in decision making in the scenarios and the effect of personality on respondents' satisfaction and wish to complain. Generally, however, when adjusting for personality, respondents' satisfaction increased (P < 0.001) with greater patient involvement illustrated in case scenarios while the wish to complain decreased (P < 0.001). Conclusion: Our findings suggest low agreeableness and high neuroticism scores are associated with lower patient satisfaction with healthcare and increased wish to complain. Irrespective of personality, however, the wish to complain seems responsive to changes in patient involvement, underscoring the importance of inclusive healthcare communication.
... A combination of social, individual and consumer perspectives to explain patient rights was observed in three articles. Most of the articles (15) (Beaupert et al., 2014;Bismark et al., 2006;Boudioni et al., 2017;Bourne et al., 2017;Cox, 2009;Gal and Doron, 2007;Gogos et al., 2011;Gulland, 2006;Harris and Wu, 2005;Jafarian et al., 2009;Middleton et al., 2007;Mirzoev and Kane, 2018;Persson, 2002;Rabinowitz, 2010;Segest, 1996) merely described the patient grievance redressal systems, and neither of the three discourses were explicit. Broadly framing patient rights as social rights accommodates the 'right to health (care)' and obligates the states to take legal measures to improve psychological, physical and financial access to quality healthcare to members of the population, leaving no one behind. ...
... Social status also determines an individual's ability to complain, and studies show that ethnic minorities, racial minorities, people with poor economic status, rural consumers, patients with low social capital, the elderly and migrants are less likely to complain about care processes (Beaupert et al., 2014;Bismark et al., 2006;Donovan and Madden, 2018; European Union Agency for Fundamental Rights, 2013; Harris and Wu, 2005;Schlesinger et al., 2002). Impartial-The complaint procedures and the dispute-resolution processes should establish a trust relationship among the complainant, authorities and staff responsible for handling the complaints. ...
... Outcomes-Although attribution is difficult, the impact of an effective grievance redressal system is presumed to enhance overall health system accountability, improve performance of healthcare professionals and improve healthcare quality (Bismark et al., 2006;Dew and Roorda, 2001;Gogos et al., 2011;Harris and Wu, 2005;Paterson, 2002;Schlesinger et al., 2002;Townend et al., 2016). ...
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The notion of patient rights encompasses the obligations of the state and healthcare providers to respect the dignity, autonomy and equality of care-seeking individuals in healthcare processes. Functional patient grievance redressal systems are key to ensuring that the rights of individuals seeking healthcare are protected. We critically examined the published literature from high-income and upper-middle-income countries to establish an analytical framework on grievance redressal for patient rights violations in health facilities. We then used lawsuits on patient rights violations from the Supreme Court of India to analyse the relevance of the developed framework to the Indian context. With market perspectives pervading the health sector, there is an increasing trend of adopting a consumerist approach to protecting patient rights. In this line, avenues for grievance redressal for patient rights violations are gaining traction. Some of the methods and instruments for patient rights implementation include charters, ombudsmen, tribunals, health professional councils, separating rules for redressal and professional liability in patient rights violations, blame-free reporting systems, direct community monitoring and the court system. The grievance redressal mechanisms for patient rights violations in health facilities showcase multilevel governance arrangements with overlapping decision-making units at the national and subnational levels. The privileged position of medical professionals in multilevel governance arrangements for grievance redressal puts care-seeking individuals at a disadvantaged position during dispute resolution processes. Inclusion of external structures in health services and the healthcare profession and laypersons in the grievance redressal processes is heavily contested. Normatively speaking, a patient grievance redressal system should be accessible, impartial and independent in its function, possess the required competence, have adequate authority, seek continuous quality improvement, offer feedback to the health system and be comprehensive and integrated within the larger healthcare regulatory architecture.
... In addition to the list mentioned above, poor knowledge on complaint procedures, perceived feeling of powerlessness, a suspicion that a complaint will not bring any change, fear of being seen as trouble-makers by the care providers and potential negative consequences on the care received owing to the complaint raised are barriers for care-seeking individuals to raise complaints. [7][8][9][10][11][12][13][14][15] This is why care-seeking individuals who come forward to raise a complaint against a healthcare professional or a health facility often complain informally to frontline workers directly or prefer other informal channels for complaint resolution. Mirzoev and Kane 14 posit that the rise in informal complaints is because the formal institutional arrangements for grievance redressal are either not accessible or people have lost trust in existing mechanisms for grievance redressal or in the institutions that established them. ...
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Background Patient rights aim to protect the dignity of healthcare-seeking individuals. Realisation of these rights is predicated on effective grievance redressal for the victims of patient rights violations. Methods We used a critical case (that yields the most information) of patient rights violations reported in Karnataka state (South India) to explore the power dynamics involved in resolving grievances raised by healthcare-seeking individuals. Using interviews, media reports and other documents pertaining to the case, we explored the ‘governmentality’ of grievance redressal for patient rights violations, that is, the interaction of micropractices and techniques of power employed by actors to govern the processes and outcomes. We also examined whether existing governmentality ensured procedural and substantive justice to care-seeking individuals. Results Collective action was necessary by the aggrieved women in terms of protests, media engagement, petitions and follow-up to ensure that the State accepted a complaint against a medical professional. Each institution, and especially the medical professional council, exercised its power by problematising the grievance in its own way which was distinct from the problematisation of the grievance by the collective. The State bureaucracy enacted its power by creating a maze of organisational units and by fragmenting the grievance redressal across various bureaucratic units. Conclusion There is a need for measures guaranteeing accountability, transparency, promptness, fairness, credibility and trustworthiness in the patient grievance redressal system. Governmentality as a framework enabled to study how subjects (care-seeking individuals) are rendered governable and resist dominant forces in the grievance redressal system for patient rights violations.
... Accidental patient injury in surgery remains a significant burden. There are an estimated 4000 "never event" claims per year (Mehtsun et al., 2013), while the full range of avoidable complications and accidental injuries is between two (Morris et al., 2003) and 20 times higher (Bismark et al., 2006). New technology is intended to improve safety, efficiency, and quality. ...
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Objective Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice. Background New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes. Results Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system. Conclusion There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care. Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.
... Want niet alle ontevredenheid van patiënten leidt tot klachten, terwijl onvrede van patiënten ook tot klachten kan leiden wanneer de geleverde zorg goed was. 6,9 Patiënten noemen onprofessioneel gedrag van artsen vaak in hun klachten. 1,3,[10][11][12][13] Zulk gedrag kan zijn weerslag hebben op het vertrouwen in de dokter, de therapeutische relatie en de gezondheid van patiënten. ...
... This perspective is at odds with both patient-centered care and wise use of resources. In parallel, it is acknowledged that rates of compensation claims, patient complaints, and malpractice lawsuits (hereafter collectively referred to as "complaints") are higher within surgical specialties [5] and among patients who have experienced severe and preventable injuries while receiving health care [6] suggesting that higher risk medical procedures tend to correspond with higher rates of complaints. ...
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Background Although research findings consistently find poor communication about medical procedures to be a key predictor of patient complaints, compensation claims, and malpractice lawsuits (“complaints”), there is insufficient evidence to determine if greater patient involvement could actually affect the inclination to complain. Objectives We conducted an experimental case vignette survey that explores whether greater patient involvement in decision-making is likely to influence the intention to complain given different decisions and consequences. Methods Randomized, national case vignette survey with various levels of patient involvement, decisions, and outcomes in a representative Danish sample of men. We used prostate specific antigen (PSA) screening in men aged 45 to 70 years as the intervention illustrated in 30 different versions of a mock clinical encounter. Versions differed in the amount of patient involvement, the decision made (PSA test or no PSA test), and the clinical outcomes (no cancer detected, detection of treatable cancer, and detection of non-treatable cancer). We measured respondents’ inclination to complain about care in response to the scenarios on a 5-point Likert scale (from 1: very unlikely to 5: very likely). Results The response rate was 30% (6,756 of 22,288). Across all scenarios, the likelihood of complaint increased if the clinical outcome was poor (untreatable cancer). Compared with scenarios that involved shared decision-making (SDM), neutral information, or nudging in favor of screening, the urge to complain increased if the patient was excluded from decision-making or if the doctor had nudged the patient to decline screening (mean Likert differences .12 to .16, p < .001). With neutral involvement or nudging in favor of intervention, the desire to complain depended highly on the decision reached and on the patient’s course. This dependence was smaller with SDM. Conclusions Greater patient involvement in decision-making appears to be associated with less intention to complain about health care, with SDM resulting in the greatest reduction in complaint likelihood.
... Previous studies [2][3][4] using patient and client experiences with health care providers focused on reviews in which patients describe their positive and negative experiences. By analyzing patient complaints, health care providers can detect preventable patient safety issues with opportunities for improvement [5], enable organizational learning, and identify poor outcomes [6,7]. We also know that a small group of health care providers causes a major part of these complaints [8]. ...
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Background Regulatory bodies such as health care inspectorates can identify potential patient safety problems in health care providers by analyzing patient complaints. However, it is challenging to analyze the large number of complaints. Text mining techniques may help identify signals of problems with patient safety at health care providers. Objective The aim of this study was to explore whether employing text mining techniques on patient complaint databases can help identify potential problems with patient safety at health care providers and automatically predict the severity of patient complaints. Methods We performed an exploratory study on the complaints database of the Dutch Health and Youth Care Inspectorate with more than 22,000 written complaints. Severe complaints are defined as those cases where the inspectorate contact point experts deemed it worthy of a triage by the inspectorate, or complaints that led to direct action by the inspectorate. We investigated a range of supervised machine learning techniques to assign a severity label to complaints that can be used to prioritize which incoming complaints need the most attention. We studied several features based on the complaints’ written content, including sentiment analysis, to decide which were helpful for severity prediction. Finally, we showcased how we could combine these severity predictions and automatic keyword analysis on the complaints database and listed health care providers and their organization-specific complaints to determine the average severity of complaints per organization. Results A straightforward text classification approach using a bag-of-words feature representation worked best for the severity prediction of complaints. We obtained an accuracy of 87%-93% (2658-2990 of 3319 complaints) on the held-out test set and an F1 score of 45%-51% on the severe complaints. The skewed class distribution led to only reasonable recall (47%-54%) and precision (44%-49%) scores. The use of sentiment analysis for severity prediction was not helpful. By combining the predicted severity outcomes with an automatic keyword analysis, we identified several health care providers that could have patient safety problems. Conclusions Text mining techniques for analyzing complaints by civilians can support inspectorates. They can automatically predict the severity of the complaints, or they can be used for keyword analysis. This can help the inspectorate detect potential patient safety problems, or support prioritizing follow-up supervision activities by sorting complaints based on the severity per organization or per sector.
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Objectives Previous research has shown that patients who are older, less educated, or have lower income are less likely to lodge complaints about health care. This variation may reflect less wish to complain or inequitable access to complaint channels or remedies. We aimed to investigate associations between sociodemographic characteristics and health users’ wish to complain. Study design This was a randomized case vignette survey among 6756 Danish men aged 45–70 years (30% response rate). Methods Assuming they received the care in vignettes about prostate cancer (prostate-specific antigen) testing, participants rated their wish to complain on a 5-point Likert scale. Information on sociodemographic characteristics was obtained through self-reports and municipality-level information from national registries. Results Lower education was associated with an increased wish to complain (mean Likert difference 0.44 [95% CI 0.36–0.51]; P < .001). The wish to complain was higher among unemployed men (difference 0.16 [95% CI 0.04–0.28]; P < .011) and those with a chronic illness (difference 0.06 [95% CI 0.02–0.10]; P < .004). Given the same healthcare scenarios, there was no difference in wish to complain among health users who were retired, living rurally, or from lower income groups. Conclusions Health users who are less educated, lower income, elderly, or from rural or minority communities appear to be as likely, or more likely, to wish to complain about health care as others. Yet, younger, well-educated, and higher income citizens are overrepresented in actual complaint statistics. The finding suggests persisting inequalities in the suitability or accessibility of complaint processes for some groups of patients.
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Over the past decade there has been a renewed global commitment towards building people‐centred healthcare systems and enhancing the capture of patient complaints. Literature from Low‐ and Middle‐Income Countries (LMICs) on patient complaints is sparse. In 2016, the Primary Healthcare (PHC) Department at the Ministry of Public Health in Lebanon, developed a full grievance (complaint or inquiry) redress system. This paper aims to describe the development of the national grievance handling system and analyse 5 years' worth of grievance data (2016–2020). The study entailed a retrospective analysis of grievances relating to the care of patients treated in 237 Primary Health Centres in the national PHC network in Lebanon, lodged through the central grievance uptakes channels between 1 January 2016 and 31 December 2020. Between 1 January 2016 and 31 December 2020, the PHC Department at the ministry of health received 562 grievances from a total of 389 unique beneficiaries Management issues made up an overwhelming 70% of all grievances, followed by relationships (20%) and clinical issues (6%). Findings indicate the need to enhance the healthcare administration, monitoring and workflow at the PHC centres and to promote the utilisation of grievance systems. The study outlines lessons learned for building grievance systems in LMICs.
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Context Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high. However, some have questioned the validity of these estimates.Objective To examine the reliability of reviewer ratings of medical error and the implications of a death described as "preventable by better care" in terms of the probability of immediate and short-term survival if care had been optimal.Design Retrospective implicit review of medical records from 1995-1996.Setting and Participants Fourteen board-certified, trained internists used a previously tested structured implicit review instrument to conduct 383 reviews of 111 hospital deaths at 7 Department of Veterans Affairs medical centers, oversampling for markers previously found to be associated with high rates of preventable deaths. Patients considered terminally ill who received comfort care only were excluded.Main Outcome Measures Reviewer estimates of whether deaths could have been prevented by optimal care (rated on a 5-point scale) and of the probability that patients would have lived to discharge or for 3 months or more if care had been optimal (rated from 0%-100%).Results Similar to previous studies, almost a quarter (22.7%) of active-care patient deaths were rated as at least possibly preventable by optimal care, with 6.0% rated as probably or definitely preventable. Interrater reliability for these ratings was also similar to previous studies (0.34 for 2 reviewers). The reviewers' estimates of the percentage of patients who would have left the hospital alive had optimal care been provided was 6.0% (95% confidence interval [CI], 3.4%-8.6%). However, after considering 3-month prognosis and adjusting for the variability and skewness of reviewers' ratings, clinicians estimated that only 0.5% (95% CI, 0.3%-0.7%) of patients who died would have lived 3 months or more in good cognitive health if care had been optimal, representing roughly 1 patient per 10 000 admissions to the study hospitals.Conclusions Medical errors are a major concern regardless of patients' life expectancies, but our study suggests that previous interpretations of medical error statistics are probably misleading. Our data place the estimates of preventable deaths in context, pointing out the limitations of this means of identifying medical errors and assessing their potential implications for patient outcomes. Figures in this Article The number of deaths in US hospitals that are reportedly due to medical errors is disturbingly high. A recent Institute of Medicine report quoted rates estimating that medical errors kill between 44 000 and 98 000 people a year in US hospitals.1 These widely quoted statistics have helped create initiatives directed at patient safety throughout the United States. The numbers are undeniably startling; they suggest that more Americans are killed in US hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to 3 fully loaded jumbo jets crashing every other day.2 Widely disseminated quotes include, "medical mistakes kill 180 000 people a year in US hospitals"3 and "medical errors may be the 5th leading cause of death."4 If these inferences are correct, the health care system is a public health menace of epidemic proportions. These statistics are generally based on peer review using structured implicit review instruments. Physicians are trained to review hospital medical records and give their opinion on the occurrence of adverse events and the quality of hospital care and its impact on patient outcomes. Although the wording of the question used to assess hospital deaths has differed somewhat among studies, the studies have produced very similar conclusions. Perhaps the most often quoted study is the Harvard Medical Practice Study, which assessed negligence related to adverse events, including deaths, in New York.5 However, several other studies have asked whether deaths would have been preventable by optimal quality of care1,6- 9 and have found similar results. In an exchange about the validity of these estimates,10- 11 McDonald et al argued on theoretical grounds that these statistics are likely overestimates. They were particularly concerned about the lack of consideration of the expected risk of death in the absence of the medical error. Indeed, these statistics have often been quoted without regard to cautions by the authors of the original reports, who note that physician reviewers do not believe necessarily that 100% of these deaths would be prevented if care were optimal.12 So, the questions remain: when a reviewer classifies a death as definitely or probably preventable or due to medical errors, is there a 90% chance or a 10% chance that a death would have actually been prevented if care had been optimal? How long would patients have lived if care had been optimal? How does the interrater reliability of reviewers' ratings affect these estimates? To examine these questions, we trained physician reviewers to assess medical records and identify medical errors documented in the care of patients who died at 7 Department of Veterans Affairs (VA) medical centers and asked reviewers to estimate the probability that these deaths could have been prevented by optimal medical care.
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