What Do Consumers Need Before, During and After a Patient Safety Incident Review? A Qualitative Study.

objectivesWhen a patient (consumer) suffers serious harm that is considered preventable, healthcare organisations typically conduct a review (or investigation) of the incident to better understand what happened and why, and take action to prevent similar incidents from reoccurring. These reviews and associated other organisational responses can compound psychological harm to consumers. Understanding how consumer needs can be met during these processes may assist in reducing this harm. This study aimed to understand what is important to consumers before, during and after patient safety incident reviews, as framed by their experiences.

methodsParticipants were purposely recruited through patient advocacy organisations, including newsletter advertisements, and through consumer representatives. Semi-structured interviews were conducted over video conference with consumers and consumer representatives between April 2024 and March 2025, and transcribed verbatim. The data analysis utilised grounded theory techniques, including inductive analysis, theoretical saturation and constant comparison, to identify key needs and perspectives of consumers during patient safety incident reviews.

resultsA total of 28 participants were recruited and participated in 21 interviews and one focus group, across four states and territories in Australia (New South Wales, Victoria, the Australian Capital Territory and Queensland). Analysis identified that consumers want more empathetic, practical and inclusive support throughout patient safety incident reviews, with clearer communication, transparency and accountability. Consumers want their voices heard, valued and documented across the review. They also want opportunities for greater and more flexible involvement in the review process, and a structured mechanism to track, report and communicate implementation changes, driven by a desire to prevent patient safety incidents from recurring.

conclusionsEnsuring the response to incidents is more patient-centred, through more meaningful engagement and consideration of consumers' emotional, psychological, communication and transparency, accountability and practical needs, is an important way forward. A patient-centred relational approach, complementing systems-based reviews, will contribute to learning and improvement following an incident, enhance consumers' experience, including reducing compounded harm, and support them in regaining trust in the healthcare system. PATIENT OR PUBLIC CONTRIBUTION: There were 28 consumers with experience of patient safety reviews or as consumer representatives interviewed. This study is part of a 4-year project that includes a research advisory committee comprised of six consumers from four jurisdictions. They are involved throughout the project lifecycle and advise the project team on methodology and the broad interpretation of the data across the project. In this study, they were invited to be study participants.