Developing the Improving Post-Event Analysis and Communication Together (Impact) Tool to Involve Patients and Families in Post-Event Analysis

The analysis of harmful errors is typically led by a team within the hospital and includes clinicians and staff who were involved at the time of the event. However, the patient and family are often left out of this process and are not asked to participate in the investigation. Because little guidance is available for facilitating patient input, an interprofessional team convened to develop a semi-structured tool to be used in eliciting patient feedback. Some 72 persons who had experienced adverse events were interviewed. Using a thematic analysis approach, the team learned that 51% of the interviewees preferred to participate in event analysis directly through an interview and 47% recommended that patients and families should be offered the opportunity to provide their views immediately (within 24–48 hours of the event). The resulting tool, IMPACT, incorporates a conversational flow of questions that allows patients to tell their story, focus their attention on specific causative factors, and give recommendations to improve healthcare in their institutions or to prevent further harm.