Patient Complaints Can Reveal Surprising ED Safety Concerns
Do ED patients complain because they are seeking some type of compensation, or is it really about wanting to be heard? “In fact, most people who complain are doing so because they want to see improvement,” says David Chaulk, MD, MPH, an associate clinical professor of pediatrics in pediatric emergency medicine at the University of Utah School of Medicine.
Typically, EDs respond to complaints by offering some type of service recovery (e.g., waiving charges or expediting follow-up). This might resolve the problem for the individual patient, but the underlying issue might remain. “Patient complaints should be a key part of the department’s approach to improvement,” Chaulk says.
Complaint data are a good way to identify failures in the diagnostic process, according to a recent analysis.1 “Healthcare systems are already collecting complaint data. But it’s unclear how that data can be used to improve care,” says Traber Davis Giardina, PhD, MSW, a patient safety researcher and assistant professor at Baylor College of Medicine.
Giardina and colleagues reviewed 1,865 patient complaints submitted to Geisinger in 2017, and found 177 complaints were likely to be linked to diagnostic errors. After conducting an additional analysis, the researchers identified 39 diagnostic errors (22 of which occurred in the ED). In 2018, researchers reviewed a second group of 2,423 complaints, and identified 310 concerning reports. Further analysis uncovered five diagnostic errors (three of which occurred in the ED). “It is interesting that patients are reporting diagnostic concerns via the complaint system,” Giardina offers. Some patients specifically reported they were misdiagnosed. Others complained about returning to the ED multiple times before receiving a correct diagnosis.
Finding diagnostic errors within patient complaints is “very labor-intensive,” Giardina notes. “We need to be more thoughtful about the way we collect and categorize patient complaint data so we can address diagnostic safety issues as they emerge.”
Ideally, ED providers should be gathering feedback right away on diagnosis-related complaints. “These types of errors can have serious consequences for patients,” Giardina cautions.
Communication breakdowns are the underlying reason for most ED complaints.2-4 “In particular, cases where a diagnosis was missed or delayed should be reviewed,” Chaulk suggests. EDs often view misdiagnosis complaints as “one-offs.” This limits the opportunity to learn from them. “Unintentionally, the local response to patient complaints without systematic analysis can actually limit the power of the patient’s voice,” Chaulk says.
An ED’s approach to complaints should include viewing complaints as a failure of a process, instead of blaming an ED provider. “It is hard to receive a complaint,” Chaulk observes. “Sharing these data is hard, as it can be viewed as airing your dirty laundry.”
If complaints are tracked at the ED level, and also the hospital level, the complaint becomes less about an individual’s shortcoming, and more of a process failure. Patients often complain about how they were stuck in an ED waiting room for hours without anyone checking in, or they had no idea who or what they were waiting for. “When this is reviewed as an individual complaint, it may appear to be a failure of the individual nurse or provider,” Chaulk explains.
If a trend of similar-sounding complaints is noted, there is a process or staffing issue standing in the way of timely reassessment and good communication. “The response should be targeted improvement, rather than reprimand,” Chaulk advises.
Bear in mind that patients from minority groups, or from lower socioeconomic groups, are less likely to complain about the ED visit. It is not because they have less to complain about than other patients. “We know that there are health disparities in healthcare. These disparities also exist in patient complaints,” Chaulk notes.
Understanding the ED patient experience requires multiple sources of information. “This may include getting feedback before the patient leaves the ED,” Chaulk suggests. Unsolicited complaints about ED visits probably are the tip of the iceberg. “The complaints that are formally submitted by patients represent only a small fraction of the patients who feel that something went wrong in their care,” says Thomas H. Gallagher, MD, a professor of medicine, bioethics, and humanities at the University of Washington School of Medicine.
Gallagher and colleagues found 48% of hospitalized patients thought a harmful breakdown occurred in their care, but only 30% of those patients felt comfortable enough to speak up about what happened.5 “The lack of established doctor/patient relationship in the emergency department may actually make it less likely that patients will share their concerns with providers,” Gallagher laments.
There are two natural times during the ED visit to encourage patients to speak up. When meeting the patient, the emergency physician (EP) can say, “Healthcare today can be very complex. Please let me know right away if you have any concerns that something has not gone well in your care.” Immediately before discharge, the EP or ED nurse can ask, “Do you have any concerns that we have not addressed?”
Gerald B. Hickson, MD, says, “it’s very important to use the eyes and ears of the people who walk through the door. They help you identify your dysfunctional systems and clinical team members who can be challenged in working with others.”
ED providers may take the attitude that everybody is the subject of complaints eventually. In fact, research has shown complaints are not randomly distributed. “We know that about 3% of physicians are responsible for 40% to 50% of reports,” says Hickson, founding director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville.6
If an ED patient feels dissatisfied enough to take the time to complain, that patient is going to expect a decent response. “Some of the most loyal patients are those where we have acknowledged a problem and addressed it,” Hickson reports.
The opposite is true if a complaint goes unaddressed. “Those patients are more likely to be highly dissatisfied, seek care elsewhere in the future, share their concerns with other friends and neighbors, and — if they experience an adverse outcome — to seek legal representation,” Hickson cautions.
Patient safety should be the overarching concern whenever there is a complaint. “A sizeable number of complaints, in the 20% range, are related to safety issues specifically,” according to Hickson, who adds that a surprising number of complaints happen because of perceived disrespect. “From a risk standpoint, it’s amazing how much time we spend talking about all of those bad lawyers, when it’s more often useful to pause and say, ‘Gosh, could I have done that a little better?’”
On the other hand, complaint-prone EPs are not necessarily doing something wrong. If ED patients are demanding antibiotics or MRIs, and the ED provider says it is not indicated, those patients might complain. The answer is not to order more prescriptions and tests; it is to communicate the decision-making better. “Many in emergency medicine may say ‘It takes too much time for that extra step.’ But in some sense, it’s pay me now, or pay me later,” Hickson says.
If the EP does not explain why the desired test is not in the patient’s best interest, an unhappy patient might assume it was negligence and call a lawyer. To avoid this kind of misunderstanding, Hickson says EPs can put it this way: “I’m doing what I feel is the right care. I respect you and your questions, but I know you would not want me to offer care that’s not in your best interest.”
Some ED complaints are not misunderstandings at all; rather, something actually went wrong. A complaint about delayed stroke diagnosis could reveal the ED nurse never informed the EP about the patient’s deteriorating condition — not because the ED nurses did not recognize it, but because the EP routinely treats nurses with disrespect. “It is not always the disease condition. Too often, the avoidable outcome is related to team performance,” Hickson laments. “Whenever disrespect is modeled by the physician, patients are placed at risk.”
A new mindset about ED complaints is what is needed to reduce malpractice risks. Hickson puts it this way: “Instead of taking all your time thinking about how unreasonable people are, ask, ‘What could I have done differently?’”
- Giardina TD, Korukonda S, Shahid U, et al. Use of patient complaints to identify diagnosis-related safety concerns: A mixed-method evaluation. BMJ Qual Saf 2021 Feb 17;bmjqs-2020-011593. doi: 10.1136/bmjqs-2020-011593. [Online ahead of print].
- Taylor DM, Wolfe R, Cameron PA. Complaints from emergency department patients largely result from treatment and communication problems. Emerg Med (Fremantle) 2002;14:43-49.
- Gurley KL, Wolfe RE, Burstein JL, et al. Use of physician concerns and patient complaints as quality assurance markers in emergency medicine. West J Emerg Med 2016;17:749-755.
- Chaulk D, Krueger C, Stang AS. A retrospective review of physician-related patient complaints from a tertiary pediatric hospital. Pediatr Qual Saf 2019;4:e136.
- Fisher KA, Smith KM, Gallagher TH, et al. We want to know: Patient comfort speaking up about breakdowns in care and patient experience. BMJ Qual Saf 2019;28:190-197.
- Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA 2002;287:2951-2957.
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