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Background: Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed., Objective: To identify factors which influence speaking up, and to examine the impact of apology when problems occur., Design: Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied., Setting: National online survey., Participants: 1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate., Main Outcomes and Measures: Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital., Results: Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not 'definitely' speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer's role influenced speaking up for two of the three breakdowns (rudeness and slow response)., Conclusions: Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients' willingness to recommend the hospital., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Unprecedented numbers of physicians are practicing past age 65. Unlike other safety-conscious industries, such as aviation, medicine lacks robust systems to ensure late-career physician (LCP) competence while promoting career longevity., Objective: To describe the attitudes of key stakeholders about the oversight of LCPs and principles that might shape policy development., Design: Thematic content analysis of interviews and focus groups., Participants: 40 representatives of stakeholder groups including state medical board leaders, institutional chief medical officers, senior physicians (>65 years old), patient advocates (patients or family members in advocacy roles), nurses and junior physicians. Participants represented a balanced sample from all US regions, surgical and non-surgical specialties, and both academic and non-academic institutions., Results: Stakeholders describe lax professional self-regulation of LCPs and believe this represents an important unsolved challenge. Patient safety and attention to physician well-being emerged as key organising principles for policy development. Stakeholders believe that healthcare institutions rather than state or certifying boards should lead implementation of policies related to LCPs, yet expressed concerns about resistance by physicians and the ability of institutions to address politically complex medical staff challenges. Respondents recommended a coaching and professional development framework, with environmental changes, to maximise safety and career longevity of physicians as they age., Conclusions: Key stakeholders express a desire for wider adoption of LCP standards, but foresee significant culture change and practical challenges ahead. Participants recommended that institutions lead this work, with support from regulatory stakeholders that endorse standards and create frameworks for policy adoption., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess patient comfort speaking up about problems during hospitalisation and to identify patients at increased risk of having a problem and not feeling comfortable speaking up., Design: Cross-sectional study., Setting: Eight hospitals in Maryland and Washington, District of Columbia., Participants: Patients hospitalised at any one of eight hospitals who completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey postdischarge., Main Outcome Measures: Response to the question 'How often did you feel comfortable speaking up if you had any problems in your care?' grouped as: (1) no problems during hospitalisation, (2) always felt comfortable speaking up and (3) usually/sometimes/never felt comfortable speaking up., Results: Of 10 212 patients who provided valid responses, 4958 (48.6%) indicated they had experienced a problem during hospitalisation. Of these, 1514 (30.5%) did not always feel comfortable speaking up. Predictors of having a problem during hospitalisation included age, health status and education level. Patients who were older, reported worse overall and mental health, were admitted via the Emergency Department and did not speak English at home were less likely to always feel comfortable speaking up. Patients who were not always comfortable speaking up provided lower ratings of nurse communication (47.8 vs 80.4; p<0.01), physician communication (57.2 vs 82.6; p<0.01) and overall hospital ratings (7.1 vs 8.7; p<0.01). They were significantly less likely to definitely recommend the hospital (36.7% vs 71.7 %; p<0.01) than patients who were always comfortable speaking up., Conclusions: Patients frequently experience problems in care during hospitalisation and many do not feel comfortable speaking up. Creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience. Such efforts should consider the impact of health literacy and mental health on patient engagement in patient-safety activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Full disclosure of harmful errors to patients, including a statement of regret, an explanation, acceptance of responsibility and commitment to prevent recurrences is the current standard for physicians in the USA., Objective: To examine the extent to which primary care physicians' perceptions of event-level, physician-level and organisation-level factors influence intent to disclose a medical error in challenging situations., Design: Cross-sectional survey containing two hypothetical vignettes: (1) delayed diagnosis of breast cancer, and (2) care coordination breakdown causing a delayed response to patient symptoms. In both cases, multiple physicians shared responsibility for the error, and both involved oncology diagnoses., Setting: The study was conducted in the context of the HMO Cancer Research Network Cancer Communication Research Center., Participants: Primary care physicians from three integrated healthcare delivery systems located in Washington, Massachusetts and Georgia; responses from 297 participants were included in these analyses., Main Measures: The dependent variable intent to disclose included intent to provide an apology, an explanation, information about the cause and plans for preventing recurrences. Independent variables included event-level factors (responsibility for the event, perceived seriousness of the event, predictions about a lawsuit); physician-level factors (value of patient-centred communication, communication self-efficacy and feelings about practice); organisation-level factors included perceived support for communication and time constraints., Key Results: A majority of respondents would not fully disclose in either situation. The strongest predictors of disclosure were perceived personal responsibility, perceived seriousness of the event and perceived value of patient-centred communication. These variables were consistently associated with intent to disclose., Conclusion: To make meaningful progress towards improving disclosure; physicians, risk managers, organisational leaders, professional organisations and accreditation bodies need to understand the factors which influence disclosure. Such an understanding is required to inform institutional policies and provider training., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture., Method: All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure., Results: The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05)., Conclusions: The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.

Objective: To understand what patients and family members know about problems and failures in healthcare., Design: Qualitative, semistructured open-ended interviews were conducted with 39 patients and 80 family members about their experiences of incidents in tertiary healthcare. Nineteen interviews involved more than one respondent, yielding 100 interviews in total. Participants were recruited through advertisements in the national broadsheet and tabloid print media (43%), with the help of the health services where the incidents occurred (28%), through invitations sent out by two internet marketing companies (27%) and by consumer organisations (2%)., Setting: Interviews were conducted in the homes of the respondents or over the phone. One participant emailed her responses to the questionnaire., Results: Analysis of the interview data revealed: (1) considerable knowledge on the part of patients and relatives about health service risks, problems and incidents; (2) the insight of interviewees into care improvement opportunities; and (3) challenges faced by patients and relatives when trying to negotiate their knowledge and insights with health service staff., Conclusion: Patients (and family members) need access to structured processes ensuring dialogue with health service personnel about perceived risks, problems and incidents. Such dialogue would reveal patients' and family members' questions and knowledge about improvement opportunities, and minimise the risk that their questions and knowledge are ignored.