Review
An integrative review of patient safety in studies on the care and safety of patients with communication disabilities in hospital

https://doi.org/10.1016/j.pec.2015.10.022Get rights and content

Highlights

  • We reviewed 27 studies on the care of patients with communication disabilities.

  • Accounts of patient safety incidents were extracted from the studies for analysis.

  • Further information is needed on factors contributing up to and following patient safety incidents.

  • Family and paid carers may be a protective factor in relation to patient safety incidents.

  • Hospital staff need to listen to patients and carers who raise concerns about care.

Abstract

Objective

To review the research literature on the experiences of patients with communication disabilities in hospital according to the Generic Model of patient safety.

Methods

In 2014 and 2015, we searched four scientific databases for studies with an aim or result relevant to safety of hospital patients with communication disabilities. The review included 27 studies.

Results

A range of adverse event types were outlined in qualitative research. Little detail was provided about contributing or protective factors for safety incidents in hospital for these patients or the impact of the incidents on the patient or organisations involved.

Conclusion

Further research addressing the safety of patients with communication disabilities is needed. Sufficient detail is required to identify the nature, timing, and detection of incidents; factors that contribute to or prevent adverse events; and detail the impact of the adverse events.

Practice implications

In order to provide safe and effective care to people with communication disabilities in hospital, a priority for health and disability services must be the design and evaluation of ecologically appropriate and evidence-based interventions to improve patient care, communication, and reduce the risk of costly and harmful patient safety incidents.

Introduction

Improving the safety of the most vulnerable patients in hospital is a high priority in any self-improving health system [1], [2]. The majority of serious patient safety incidents in hospital are not well documented due to the difficulty measuring and identifying the many components that play a part in the incident [2]. In hospital, vulnerable patients with communication disabilities (i.e., impairments of body structure or function that impact upon speech, language, or communication function) face a three-fold increased risk of sustaining preventable and harmful patient safety incidents [3]. There is, however, inadequate evidence on both the causes of the increased risk and on ecologically appropriate interventions (i.e., interventions that are appropriate in the context of a busy hospital ward) to reduce risk for this patient group. Such information is needed to inform improvements to practice, develop effective policy to prevent these adverse events, and reduce the impact of any associated negative outcomes. Without evidence relating to factors influencing their safety in hospital, patients with communication disabilities will continue to experience significantly longer stays and re-admission rates as a result of harmful and preventable patient safety incidents [2]. Apart from the costs to the patient’s health and wellbeing, patient safety incidents incur substantial financial and opportunity costs to governments, hospital services, and community-based disability services and family carers, particularly if these events are associated with increased length of stay or re-admission to hospital [3].

According to the World Alliance on Patient Safety Drafting Group (2009) [4], “a patient safety incident is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient. A patient safety incident can be a reportable circumstance, a ‘near miss’, a no harm incident or a harmful incident (adverse event)” (p. 4). In this paper we use the term ‘patient safety incidents’ to embrace all of these circumstances.

At any one time, patients with communication disabilities comprise up to 15% of the hospital population. Communication disabilities affect patients’ ability to speak with and/or understand the hospital staff who care for them [3], [5]. In some hospital wards, the prevalence of communication disability may be higher—as many as 88% of adults on stroke wards have communication disabilities [6]. Adults with communication disabilities (e.g., associated with cerebral palsy, intellectual disability, stroke, motor neuron disease) have a significantly increased risk of multiple health conditions that result in them entering hospital more frequently than their non-disabled peers and remaining there longer [7], [8]. Those with lifelong or developmental disability experience a life-course of declining function with increasing age [9], and are over-represented in hospital because of their complex health conditions [10]. Indeed, young adults with cerebral palsy enter hospital up to seven times more frequently and remain there up to ten times longer than age-matched peers [7]. Although the costs to community services providing care in hospital are not known, these are likely to be substantial due to family carers taking leave from work to care, community organisations funding paid carers to provide care in addition to that provided by hospital nurses, and the substantial costs that relate to the harmful events [2]. If costs are to be decreased and patient safety, wellbeing, and satisfaction increased, new information on (a) what contributes to the system’s errors for patient safety incidents in this population, and (b) strategies to increase system resilience, is needed. Rigby et al. recommended using research methods that included interviews, chart reviews, and document analysis to gather the most comprehensive information in patient safety research [11]. Data collection for such studies needs to be guided by any evidence on the care of patients with communication disabilities that relates to patient safety. People with communication disabilities form a heterogeneous population and the research on safety issues faced by this group provides a diverse literature in terms of aims, methods and findings. Consequently, it is important to select a ‘guiding framework’ for analysis of findings across studies. Therefore, both generic and specific patient safety frameworks were compared first for their applicability to literature relevant to the safety of patients with communication disabilities in hospital.

Within the context of patient safety research, a number of conceptual models have been proposed. Conceptual models aim to show the relationship between the various concepts, factors or variables so as to explain, organise, represent or plan a certain situation or phenomenon [12]. We considered the well-supported generic patient safety models and models of patient safety located in recent literature on the care of adults with communication disabilities in hospital. Descriptions of these models and characteristics aligning with the International Classification of Patient Safety (ICPS) [15] are presented in Table 1, Table 2.

The two main types of model that exist are causal and descriptive, with some models including elements from both categories [13]. Causal models act to explain through the explicit linking of concepts, the direct path to an endpoint or outcome. In comparison, a descriptive model includes all components relating to the outcome. Therefore, a causal model can be used to generate and test a hypothesis relating to the outcome, whereas a descriptive model is more useful for organising the various components of the situation or phenomena [13]. It is also important to define the model’s context as this can impact upon its interpretation [14]. Furthermore, patient safety incidents do not occur in isolation, but within health systems in which contributing factors and hazards cause failures that lead to the incident [2].

Accordingly, a number of conceptual models relating to patient safety have been proposed and these differ in their components and the associated relationships. Vincent et al. [17], [18] described a framework to systematically evaluate the various system factors influencing patient safety. This model extends Reason’s organisational-accident model [19] in being adapted for clinical settings with classification of factors and conditions relating to the organisation, staff, task and patient factors [17], [18].

The Systems Engineering Initiative for Patient Safety (SEIPS) [20] is a model that extends the early work of Donabedian and the Structure-Process-Outcome model [21]. SEIPS focuses on the work system component (i.e. “Structure”), and includes elements derived from ergonomics and human factor disciplines. The “individual” at the centre of the SEIPS model can be any person involved in the care of the patient and/or the patient. As such, this model is tailored to support the performance of each individual.

In 2006, Runciman [1] introduced a “generic framework” to model patient safety that is underpinned by a risk management structure. The model is split into three broad categories: (1) contributing factors and hazards, (2) the incident, and (3) outcomes and consequences. The conceptual ‘generic model’ described by Runciman et al. [2], encapsulates: contributing factors and hazards (environmental, organisational, human, subject of incident, drugs-equipment-documentation). These lead to the incident(any incident that could have led or did lead to damage-loss-harm, a near miss or adverse event, with characteristics of demographics, person involved, timing of incident, timing of detection, method of detection, preventability included). This in turn leads to (3) factors minimising or aggravating outcomes or consequences, which lead to (4) outcomes and consequences: (a) Health Care Outcome for the subject, or (b) Consequences for the Organisation; leading to (5) Overall Outcome (Actual or Potential) and Resource Impact and Risk Rating. Within this model, patient safety incidents are followed by factors to minimise or aggravate outcomes, including both health outcomes and consequences for the patient and the organisation [2]. Attention to the possible causes of risk along with strategies to deal with problems can help with developing system resilience for the prevention of future incidents [4], [15]. Finally the International Classification for Patient Safety (ICPS) [4], [15], [16] is a classification framework that comprises 10 higher-level classes of patient safety, with each class further categorised into a hierarchical structure. This model builds upon the previous work of Runciman [1] and comprises elements of risk identification, prevention, detection and reduction, incident recovery and system resilience. The ICPS is an initiative of the World Health Organisation and aims to encourage patient safety research to incorporate a standardised framework and terminology to aid in the systematic collections and analysis of data, and in turn, improve its synthesis and use.

Specific patient safety frameworks have been developed for conditions including chronic kidney disease (see [29]) and mental health problems [30]. Such frameworks lead to prevention strategies and improvements in care [15]. Currently, there are no specific patient safety frameworks comprehensively outlining contributing factors, incidents, and consequences available for people with communication disabilities of any kind. Yet this group has a high risk of having a safety incident or adverse event in hospital [3].

With an increased recognition of the health needs of people with a disability in hospital [see reviews 14–18] there is now an extant literature on the care experiences and needs of people with disabilities affecting communication [22]. Literature reviews to date have a focus upon various groups of patients with communication disabilities: older carers of adults with cerebral palsy and complex communication needs [23]; patients with severe communication impairment [24]; patients with aphasia on a stroke ward [25]; patients with intellectual disability [26], [27], [28]; and patients with severe communication disability [22], [28].

In the context of (a) an extant literature on the care of adults with various types of communication disabilities in hospital, (b) knowledge that these patients face a three-fold increased risk for adverse events in hospital [3] and (c) evidence of extreme harms related to poor care for adults with disabilities, there is a substantial gap in the literature relating to the safety of adults with communication disabilities in hospital. Therefore, the aims of this study were to identify findings relating to patient safety in reports of original research investigating the care or safety of adults with communication disabilities in hospital, and to analyse these findings according to the ‘generic model’ of patient safety [2]. The results of this study can be used to inform (a) improvements to policy and practice in both hospital and disability services, and (b) future research investigating patient safety of adults with communication disabilities in hospital. This in turn that might serve to improve patient safety and reduce the incidence of preventable harmful patient safety incidents.

Section snippets

Search terms and search strategy

On 24th August 2014, and in a follow-up check on 27 April 2015, we searched four scientific databases (Embase, Web of Science, CINAHL, Medline) for studies relevant to safety in hospital for patients with communication disabilities. The following search terms were used in various combinations and permutations: (i) Safety terms: patient safety incident, adverse event, safe/ty, unsafe, harm/ful event, critical incident, sentinel event, and variants; (ii) Setting terms: hospital, ward,

Contextual information about the population, hospital settings and studies

Of the 27 included studies, 22 related to adults with communication disabilities, and 5 related to children with communication disabilities [31], [35], [36], [37], [38]. The populations included in the studies were: patients with cerebral palsy (n = 9); patients with intellectual/learning disability (n = 9); patients with developmental disability unspecified (n = 5); patients with acquired communication disabilities (progressive conditions, aphasia following stroke, or TBI) (n = 2), children with

Discussion

As the vast majority of the studies included in this review relied on participant reports it is not possible to determine the extent to which the patients’ communication disabilities were directly related to the adverse events reported. Consequently the results of this review must be viewed in the context of limited research. Nonetheless, the commonality in reported narratives across multiple studies (see Table 6) increases the plausibility of claims about the poor quality of care and risks to

Acknowledgements

This work was supported by a grant from the National Health and Medical Research Council of Australia APP1042635. All authors have materially participated in the search, review, article preparation with the following roles: Hemsley led the review, search, provided second rater on papers, provided a lead role in authorship, supervised Rollo, Steel, and research assistants; Georgiou Balandin and Hill contributed to the data analysis and reporting, Steel assisted through data extraction and was

References (61)

  • R. Hurtig et al.

    Augmentative and Alternative Communication in Acute and Critical Care Settings

    (2009)
  • R. O’Halloran et al.

    The number of patients with communication related impairments in acute hospital stroke units

    Int. J. Speech Lang. Pathol.

    (2009)
  • H. Beange et al.

    Medical disorders of adults with mental retardation: a population study

    Am. J. Ment. Retard.

    (1995)
  • D. Strauss et al.

    Decline in function and life expectancy of older persons with cerebral palsy

    NeuroRehabilitation

    (2004)
  • R.A. Wallace et al.

    On the need for a specialist service within the generic hospital setting for the adult patient with intellectual disability and physical health problems

    J. Intellect. Dev. Disabil.

    (2008)
  • K. Rigby et al.

    Adverse events in health care: Setting priorities based on economic evaluation

    J. Qual. Clin. Pract.

    (1999)
  • J.A. Earp et al.

    Conceptual models for health education research and practice

    Health Educ. Res.

    (1991)
  • Y. Paradies et al.

    Conceptual diagrams in public health research

    J. Epidemiol. Community Health

    (2005)
  • D.W. Britt et al.

    Increasing the capacity of conceptual diagrams to embrace contextual complexity

    Qual. Quant.

    (2013)
  • World Health Organisation

    Conceptual Framework for the International Classification for Patient Safety (v 1.1)—Technical Report and Technical Annexes

    (2009)
  • W. Runciman et al.

    Towards an international classification for patient safety: key concepts and terms

    Int. J. Qual. Health Care

    (2009)
  • C. Vincent et al.

    Framework for analysing risk and safety in clinical medicine

    BMJ

    (1998)
  • C. Vincent et al.

    How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol

    BMJ

    (2000)
  • J. Reason

    Understanding adverse events: Human factors

    Qual. Health Care

    (1995)
  • P. Carayon et al.

    Work system design for patient safety: the SEIPS model

    Qual. Saf. Health Care

    (2006)
  • A. Donabedian

    The quality of care: how can it be assessed?

    JAMA

    (1988)
  • B. Hemsley et al.

    A metasynthesis of patient-provider communication in hospital for patients with severe communication disabilities: informing new translational research

    Augment. Altern. Commun.

    (2014)
  • B. Hemsley et al.

    Older unpaid carers’ experiences supporting adults with cerebral palsy and complex communication needs in hospital

    J. Dev. Phys. Disabil.

    (2007)
  • E.H. Finke et al.

    A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication

    J. Clin. Nurs.

    (2008)
  • R. O'Halloran et al.

    Environmental factors that influence communication between people with communication disability and their healthcare providers in hospital: a review of the literature within the International Classification of Functioning, Disability and Health (ICF) framework

    Int. J. Lang. Commun. Disord.

    (2008)
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