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Compensation Claims in Danish Emergency Care: Identifying Hot Spots and Blind Spots in the Quality of Care

Open AccessPublished:February 01, 2022DOI:https://doi.org/10.1016/j.jcjq.2022.01.010

      Background

      The Healthcare Complaints Analysis Tool (HCAT) offers a validated way of systematically extracting content from patient complaints for further analysis of complaint hot spots with harm or near misses, and blind spots with, for example, systemic problems or quality problems arising during discharge. This study analyzed a Danish national sample of compensations claims about emergency care using the HCAT.

      Methods

      Through use of the HCAT, compensation claims about Danish emergency care from 2013 to 2017 (N = 712) were coded and then grouped to identify and highlight hot spot problem areas (harm and near misses) and blind spot problem areas (admission/discharge, systemic problems, errors of omission). Two assessors coded the compensation claims by entering data into a database.

      Results

      The HCAT analyses of the sample resulted in coding of 1,305 problems. Most problems concerned quality and safety issues at the examination/diagnosis stage of care (63.9%). In 91.2% of the cases, the level of harm was moderate or major. Harm hot spots most often involved diagnostic errors (189 problems). Eighty-nine problems related to errors of omission, all causing moderate or major harm. For systemic blind spots, patient harm significantly increased in cases of multiple problem types in the compensation claim (odds ratio = 1.6, 95% confidence interval = 1.3–2.0).

      Conclusion

      Systematic coding and analytic approach to the HCAT can highlight potential quality problems in emergency care and point to areas for further consideration. From the perspective of future health care harm prevention, there seems to be a strong incentive for further analysis of the amount, nature, and prevention of diagnostic errors in emergency care.
      One way to improve quality in health care is to systematically analyze the complaints sent in by patients or their relatives and then identify the areas or situations most frequently associated with complaints. This approach expands the perspective of quality improvement to encompass patient reports of care experiences.
      • Gallagher TH
      • Mazor KM.
      Taking complaints seriously: using the patient safety lens.
      Patient complaints are uncensored opinions on the quality of care. Using this valuable source of information allows exploration of patient-guided areas of substandard care that are currently not recognized by clinicians.
      • Morsø L
      • et al.
      Quantification of complaint and compensation cases by introducing a Danish translated and cross-cultural adapted edition of the Healthcare Complaints Analysis Tool.
      It reflects the increasing recognition that information from patients in general and information in patient complaints are of value to clinical practice and to patient safety research in particular.
      • Gallagher TH
      • Mazor KM.
      Taking complaints seriously: using the patient safety lens.
      The Healthcare Complaints Analysis Tool (HCAT) offers one way of characterizing patient complaints, and its use is gaining ground.
      • Gillespie A
      • Reader TW.
      The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.
      • Wallace E
      • et al.
      Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      • Reader TW
      • Gillespie A
      • Roberts J.
      Patient complaints in healthcare systems: a systematic review and coding taxonomy.
      Birkeland et al. recently used the HCAT to categorize the contents of 1,613 compensation claims relating to Danish emergency care services during a time of major structural reorganization.
      • Birkeland S
      • et al.
      Changes in compensation claim contents following reorganization of emergency hospital care.
      They found that most claims concerned the HCAT domain of clinical problems, and following reorganization there was a shift toward fewer complaints about the care provided (in terms of neglect) and about staff competencies.
      • Birkeland S
      • et al.
      Changes in compensation claim contents following reorganization of emergency hospital care.
      Although most Danish compensation claims appear to be centered on the “clinical problems” domain, it is still uncertain how to ensure extraction of the information most crucial to improving patient safety. The developers of the HCAT used the tool to investigate areas of hot spots and blind spots. Hot spots refers to areas where harm and near misses accumulate, and blind spots refers to aspects of care that are difficult to monitor in health care complaints in the UK.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      The problems identified through complaints and compensation cases in the UK may very well mirror major problem areas in other countries’ health care systems. On the other hand, there may be differences due to variations in the organization of health services; for example, the presence of specialists as frontline clinicians. Similarly, the pattern and number of complaint cases might differ according to the clinical setting. Problem areas in the emergency health care setting could be different from other health care areas because of the special features of quick patient turnover, limited time, and hurried decision making, which may affect health care's clinical behavior and patient experiences. When decision making and care provision is quickened, the risk of harm and inattention may increase. Awareness about hot spot and blind spot areas therefore may provide important information and shed light on specific issues important to quality improvement in emergency care.

      Aim

      This study aimed to analyze a national Danish sample of compensations claims coded by the HCAT taxonomy to identify areas of hot spots and blind spots regarding emergency care.

      Methods

      Setting

      The Danish Patient Compensation Association (PCA) handles all health care compensation claims in the country and is responsible for obtaining relevant written information from claimants and information from health records from the health care providers. Experts appointed by the PCA assess the compensation claims with reference to the laws on injury compensation requirements. If predefined criteria for obtaining compensation are fulfilled, and compensation exceeds a triviality threshold (roughly €1,000), the patient is entitled to financial compensation for health expenses, lost earnings, pain and suffering, permanent injury, loss of ability to work, and funeral expenses.

      Bekendtgørelse af lov om klage- og erstatningsadgang inden for sundhedsvæsenet995/2018. [Executive Order of the Act on Access to Complaints and Compensation in the Health Service 995/2018]. Jun 14, 2018. Accessed Feb 9, 2022. https://www.retsinformation.dk/eli/lta/2018/995.

      Patient, relatives, or health care staff file the compensation claims free of charge to PCA, by filling in a standardized form online. PCA compensation claims are available for relevant research if the necessary approvals are in place.
      • Tilma J
      • et al.
      No-fault compensation for treatment injuries in Danish public hospitals 2006-12.
      Complaint measures are somewhat different across countries. The compensation claims used in the study constitute one category among different kinds of complaint cases defined by Gillespie and Reader.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      Among other complaint systems in Denmark is the nonmonetary disciplinary complaint system.
      The current study was based on a subsample of health care compensation claims previously reported.
      • Birkeland S
      • et al.
      Changes in compensation claim contents following reorganization of emergency hospital care.
      ,
      • Birkeland S
      • et al.
      Healthcare inequality in compensation claims concerning acute hospital services: a Danish register-based study.
      The original sample used computer-based cluster sampling (geographical regions, before and after emergency care reorganization, accepted and rejected) to identify 1,613 accepted PCA cases related to Danish emergency care from 2007 to 2017. To include only compensation claims arising after emergency care reorganization in 2012, the current study used all the compensation claims submitted by patients and relatives from 2013 to 2017, providing 712 accepted claim cases.

      The Healthcare Complaints Analysis Tool

      The HCAT was used
      • Reader TW
      • Gillespie A
      • Roberts J.
      Patient complaints in healthcare systems: a systematic review and coding taxonomy.
      ,
      • Tilma J
      • et al.
      No-fault compensation for treatment injuries in Danish public hospitals 2006-12.
      ,
      • Schnitzer S
      • et al.
      Complaints as indicators of health care shortcomings: which groups of patients are affected?.
      • Birkeland S
      • et al.
      Patient complaint cases in primary health care: what are the characteristics of general practitioners involved?.
      • Harrison R
      • et al.
      Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.
      to code and quantify the different types of problems in the compensation claims. Gillespie and Reader published the HCAT in 2016 as a standardized tool for codifying, analyzing, and assessing complaints and compensation cases.
      • Gillespie A
      • Reader TW.
      The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.
      Since then, several other countries have applied the HCAT in the systematic assessment of complaint and compensation cases in health care systems.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      ,
      • Tilma J
      • et al.
      No-fault compensation for treatment injuries in Danish public hospitals 2006-12.
      ,
      • Harrison R
      • et al.
      Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.
      • Bogh SB
      • et al.
      Healthcare Complaints Analysis Tool: reliability testing on a sample of Danish patient compensation claims.
      • Tilma J
      • et al.
      Existing data sources for clinical epidemiology: the Danish Patient Compensation Association database.
      The HCAT taxonomy condenses data into a hierarchy of 3 domains, 7 problem categories, and 36 subcategories. The HCAT assesses the severity of each problem and the overall harm caused. HCAT also displays the stage of care at which the complaint occurred, who filed the complaint, the gender of the patient, and which staff groups were involved in the complaint (see Appendix 1, available in online article).

      Assessment and Coding

      Using the HCAT to code compensation claims requires an introduction to the coding concept. The HCAT manual must be read and an online course completed before a user is allowed to code any actual cases.
      • Gillespie A
      • Reader TW.
      The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.
      ,
      • Bogh SB
      • et al.
      Healthcare Complaints Analysis Tool: reliability testing on a sample of Danish patient compensation claims.
      Following this introduction, two assessors, both of whom were academics, individually reviewed the compensation claims in the PCA electronic case management system
      • Bogh SB
      • et al.
      Healthcare Complaints Analysis Tool: reliability testing on a sample of Danish patient compensation claims.
      using a Web-based coding form based on the English HCAT manual. We used REDCap (Research Electronic Data Capture) as a Web platform. The coding of the original sample was used in this study as well.
      The assessors read the entire compensation claim and then used the Web-based form to access the four phases for coding a health care complaint according to the HCAT classification system
      • Reader TW
      • Gillespie A
      • Roberts J.
      Patient complaints in healthcare systems: a systematic review and coding taxonomy.
      ; (see the overview in Table 1 and Appendix 1 for more detail).
      Table 1Overview of the Healthcare Complaints Analysis Tool (HCAT)
      Overview of the HCAT Classification System
      A. Identifying the presence of problem categories (and, if required, subcategories) within the letter of complaint using the coding taxonomy, and assessing their severity (rated from 0 = not evident, to 3 = high severity). Severity is independent of outcome (that is, harm).
      B. Specifying the stages of care at which problems occurred (Admission, Examination & diagnosis, Care on the ward, Operations & procedures, Discharge & transfers, other/Unspecified)
      C. Indicating the level of harm arising from the reported problem (rated from 0 = none/no information about harm, to 5 = catastrophic harm).
      D. Providing descriptive information about the letter of claimant (who filed the complaint, the gender of the patient, and the staff group involved).

      Definitions of Hot Spots and Blind Spots

      Gillespie and Reader identify the following two types of hot spots and three types of blind spots5:
      • Harm hot spots are complaints coded to be of major or catastrophic harm.
      • Near-miss hot spots are cases of high severity and minimal or minor harm.
      • Entry/exit blind spots are defined by complaints regarding stages either before/during admission or during/after discharge.
      • Omission blind spots are defined by cases present only at one stage of care, extracted from neglect and ignoring categories across the coding matrix domains.
      • Systemic blind spot areas are defined by complaints across different stages of care, that fall under multiple complaint categories, and in which more than one staff member was involved.

      Statistical Analysis

      We first overviewed the number of compensation claims in each of the 3 HCAT domains, the 7 problem categories, and the 36 subcategories. To identify hot spot and blind spot areas, we used the following definitions by Gillespie and Reader
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      :
      • 1.
        The subcategories that had the highest number of complaints causing major or catastrophic harm (harm hot spots)
      • 2.
        The subcategories that had the highest number of complaints with high severity and minimal or minor harm (near-miss hot spots)
      • 3.
        The subcategories that had the highest number of complaints occurring before/during admission or during/after discharge (entry/exit blind spots)
      • 4.
        The stages of care that were linked to the highest number of complaints on the subcategories of “neglect” and “ignoring” (omission blind spots)
      • 5.
        The level of harm caused by cases involving different stages of care, complaint categories, and staff (systemic blind spots)
      For each hot spot and blind spot, we noted the severity of cases and the staff group involved. For near-miss hotspots and entry/exit blind spots, case examples under each subcategory are given. To analyze differences of systemic blind spots, we used an ordered logit regression model including staff, category, and stage variables.
      All data management and analyses were performed in Stata 15 (StataCorp LLC, College Station, Texas).

      Ethics

      The Danish Data Protection Agency and the PCA approved the data handling (project approval 17/18 411). Danish law does not require approval from the ethics committee for this type of study (Act on Research Ethics Review of Health Research Projects, 1338, dated September 1, 2020).

      Results

      The study included 712 patient compensation cases mostly filed by patients (84.1%) to the PCA from 2013 to 2017. On average, each case contained 1.83 complaint points (1,305 complaint points in total). Roughly half (47.1%) of the claimants were women, and the annual number of cases was relatively stable over the five years. The HCAT coding showed that a large proportion (71.8%) of the cases did not specify a staff group as the subject for the complaint.
      The majority of the claim problems coded were equally distributed between the “quality” and “safety” problem categories—40.8% and 43.1%, respectively. A substantial number of these cases referred to issues in both problem categories. A high proportion of the quality cases had a “high” severity (63.2%), in contrast to safety cases that were primarily of “medium” severity (83.1%). In this emergency care cohort, complaints were mainly linked to the “examination and diagnosis” stage of care (63.9%). In 91.2% of the cases, the level of harm was coded as “moderate” or “major” (Table 2).
      Table 2Patient and HCAT Claim Characteristics from 712 Patient Compensation Cases Containing 1,305 Complaint Points Related to Emergency Care
      Characteristics
      Age (years), mean (IQR)46 (27–59)
      Women, n (%)335 (47.1)
      Year of Registration, n (%)
      2013134 (18.8)
      2014144 (20.2)
      2015148 (20.8)
      2016151 (21.2)
      2017135 (19.0)
      Domain
       • Problem Category, n (%)
        ○ Severity, n (%)
      Clinical
       • Quality533 (40.8)
        ○ Low severity16 (3.0)
        ○ Medium severity180 (33.8)
        ○ High severity337 (63.2)
       • Safety562 (43.1)
        ○ Low severity11 (2.0)
        ○ Medium severity467 (83.1)
        ○ High severity84 (14.9)
      Relationship
       • Listening77 (5.9)
        ○ Low severity3 (3.9)
        ○ Medium severity47 (61.0)
        ○ High severity27 (35.1)
       • Communication31 (2.4)
        ○ Low severity5 (16.1)
        ○ Medium severity23 (74.2)
        ○ High severity3 (9.7)
       • Respect and patient rights22 (1.7)
        ○ Low severity15 (68.2)
        ○ Medium severity6 (27.3)
        ○ High severity1 (4.5)
      Management
       • Environment20 (1.5)
        ○ Low severity6 (30.0)
        ○ Medium severity9 (45.0)
        ○ High severity5 (25.0)
       • Institutional60 (4.6)
        ○ Low severity5 (8.3)
        ○ Medium severity40 (66.7)
        ○ High severity15 (25.0)
      Stage of care, n (%)
      Admissions10 (1.4)
      Examination and diagnosis455 (63.9)
      Care on ward17 (2.4)
      Operations and procedures182 (25.6)
      Discharge and transfers40 (5.6 )
      Other/unspecified8 (1.1)
      Level of harm, n (%)
      None/unspecified4 (0.6)
      Minimal3 (0.4)
      Minor35 (4.9)
      Moderate195 (27.4)
      Major454 (63.8)
      Catastrophic21 (2.9)
      Staff complained about, n (%)
      Administrative1 (0.1)
      Physicians179 (25.1)
      Nursing21 (2.9)
      Other/unspecified511 (71.8)
      Claimant, n (%)
      Family member77 (10.8)
      Patient599 (84.1)
      Other/unspecified36 (5.1)
      HCAT, Healthcare Complaints Analysis Tool; IQR, interquartile range.

      Hot Spots: Harm

      Figure 1 displays the three most frequent harm hot spot areas. All three were located under the clinical domain comprising “quality” and “safety” problem categories and at the “examination and diagnosis” stage. The harm hot spot with the most complaints was the subcategory “error diagnosis” (under “safety”) and consisted of 189 cases, of which 188 cases were medium or high severity. The following statement is from one of the high severity cases:I was taken to the ER with stroke symptoms. I was discharged with the diagnosis migraine. After a few weeks I could feel that something was still wrong and my GP referred me to the hospital for further examinations 3 months later. They scanned me and discovered that I had had a stroke.
      Figure 1:
      Figure 1Shown here are the three most frequent HCAT (Healthcare Complaints Analysis Tool) harm hot spot subcategories according to stage of care, including the staff group complained about.
      The second harm hot spot was the subcategory “outcome and side effects” (under the “quality” problem category) and consisted of 160 cases, of which 116 were high severity. From one of the high severity outcome and side effects cases one patient stated:A really bad course in the treatment of kidney stones. The catheter, which was to sit for about 14 days, ended with sitting for about 12 weeks. Even though I had major inconveniences. My own doctor thinks there is a connection between the violent removal of the catheter and problems to hold on to the urine today.
      The third harm hot spot was the subcategory “examination and monitoring” (under the “quality” problem category) and consisted of 125 cases, of which 100 were of high severity. In an example of a high severity case within this category, the complainant stated:I was hit by a truck in high speed and my car suffered total damage. Shortly after the accident I was admitted to the hospital. A very superficial examination was performed and despite a swollen foot and leg and pain in my back and neck no further examinations were done. . . . four months later I was told that I had a complicated fracture in my ankle and the doctor apologized that they hadn't found out earlier. . . . I now have a permanent foot drop.
      Most complaints (60.8) in all three hot spots were not directed at medical or nursing staff members.

      Hot Spots: Near Miss

      Only 10 near-miss hot spot cases of minimal or minor harm were identified (Figure 2). Five of the 10 cases were included in the quality subcategory “examination and monitoring” at the “examination and diagnosis” stage. In one example, the patient describes a lack of examination and monitoring due to the staff in the emergency department being too busy.
      Figure 2:
      Figure 2Shown here are the most common HCAT (Healthcare Complaints Analysis Tool) near-miss hot spot subcategories according to stage of care, including examples of statements from compensation claims.

      Blind Spots: Entry/Exit

      We found 17 cases coded as entry/exit blind spots, of which 7 were “institutional processes” within the subcategories of “bureaucracy” (n = 4), “delay in access” (n = 1), or “delay in procedure” (n = 2) (Figure 2). In one case, the claimant's wife waited for five hours despite obvious signs of serious illness. A second blind spot area was the subcategory “absent communication” (n = 3). Here one of the cases referred to increased pain and inconvenience caused by prolonged waiting time due to lack of information (Figure 2).

      Blind Spots: Errors of Omission

      We found 89 cases related to “errors of omission,” of which 47 occurred during “examination and diagnosis” and 32 during “ward procedures” (Figure 3). The two most frequent error of omission blind spots during examination and diagnosis were related to “general neglect” (the “quality” problem category), with 24 cases, and “ignoring patients” (the “listening” problem category) with 12 cases; in all of those 36 cases, patients experienced major harm. A third error of omission blind spot was at the ward procedures stage in the subcategory of general neglect (quality), with 16 cases.
      Figure 3:
      Figure 3Shown here are the most common HCAT (Healthcare Complaints Analysis Tool) “errors of omission” subcategories within stage of care and level of harm caused, including the staff group complained about.
      Of the 40 omission blind spots coded as general neglect, 23 complaints were not directed toward medical or nursing staff but coded as “other/unspecified.” In contrast, 8 of 12 cases coded as “ignoring patients” were raised against medical or nursing staff. Although most errors of omission were coded as medium severity, they were mostly rated as causing moderate or major harm (Figure 3).

      Blind Spots: Systemic

      Systemic blind spot cases involve complaints across care stages, multiple complaint categories, or multiple staff involvement. Figure 4 shows all 1,305 complaint points grouped according to the level of harm caused (from “unspecified” to “catastrophic” harm), related to the number of care stages involved in the complaint (Figure 4a), the number of problem categories involved (Figure 4b), and the number of staff groups involved (Figure 4c).
      Figure 4:
      Figure 4These graphs show the level of harm associated with (a) number of stages of care, (b) number of categories, and (c) number of staff involved for all 1,305 complaint points.
      Figure 4a indicates that the level of harm associated with the complaint did not increase with additional stages of care until the involvement of four or more stages (odds ratio [OR] = 0.91, 95% confidence interval [CI] = 0.65–1.29, showing statistically insignificant differences).
      In contrast, Figures 4b and 4c suggest that the level of harm increased when more categories of complaints were involved or when the complaint was directed toward more than one staff group. We found that the level of harm caused was significantly associated with the number of categories involved (OR = 1.6, 95% CI = 1.3–2.0), but an association between increased harm and the number of staff groups involved could not be established (OR = 1.8, 95% CI = 0.9–3.4).

      Discussion

      This study shows how patient complaints can be used to recognize potentially harmful and sometimes hardly detectable problem areas in health care quality that need further consideration. We used the HCAT taxonomy in a Danish national sample of compensation claims from emergency care to identify hot spot and blind spot areas in the quality of care from a patient perspective. Based on harm hot spots identified in compensation claims about emergency care, the examination and diagnosis stage of care is a particularly critical area (diagnostic errors, undesirable outcomes and side effects, and incidents during examinations and monitoring). Although it is natural to pay most attention to areas where patients experience major harm, patient complaint letters also reveal hot spot near misses—high severity cases in which the patient was not harmed. Even if no harm occurs, patients may perceive “near miss” episodes as very unpleasant. In order to take patient involvement seriously, health care organizations are obliged to learn from patients’ experience of near misses. In addition to the areas mentioned above, our analysis suggests that clinicians should be aware of the possibility of causing significant harm through inadequate communication during discharge and transfers.
      Health care organizations often focus only on those complaint cases causing major or catastrophic harm when learning from complaint cases, and it might be harder to draw learning from cases that are difficult to detect due to degree of harm or organization of health care provision. Therefore, blind spots are also important to draw attention to as they may consist of several, perhaps small, events and are easily overlooked. Errors of omission blind spots were typically related to general neglect (particularly during examination and diagnosis and ward procedures) and staff ignoring patients. The analysis also showed that patient pathways with multiple complaint points across problem categories were associated with increased patient harm (systemic blind spots).
      Our finding that harm hot spots dominate at the examination and diagnosis stage differs from the findings of Gillespie and Reader.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      Major and catastrophic harm were associated with the examination and diagnosis stage, but they also found increased harm at other stages of care. For example, among complaints reported as catastrophic harm, 36% were related to care on the ward.
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      We found that diagnostic error was the most common harm hot spot subcategory, and this does not appear to be restricted to Denmark. In a UK study, Hussain et al. found 5,412 reports that included diagnostic error, of which 2,288 (42.3%) occurred in emergency department settings, mostly reflecting diagnostic delay (86.2%).
      • Hussain F
      • et al.
      Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
      A Belgian study by Moonen et al. found that fractures were the most common condition with diagnostic error, primarily due to inadequate history taking/physical examination or incorrect ordering/interpretation of para-clinical examinations.
      • Moonen PJ
      • et al.
      Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.
      Moreover, diagnostic error seems to present in primary care settings as well. Singh et al. showed that, in 190 cases, 68 unique diagnoses were missed.
      • Singh H
      • et al.
      Types and origins of diagnostic errors in primary care settings.
      From US reports of adverse medical events, Giardina and colleagues previously identified patient narratives of diagnostic error and found that problems related to patient-physician interactions emerged as major contributors, reflecting unprofessional clinician behavior such as ignoring or disrespecting patients’ knowledge.
      • Giardina TD
      • et al.
      Learning from patients’ experiences related to diagnostic errors is essential for progress in patient safety.
      And recently, from a review of 4,288 patient complaint summaries and corresponding medical records, Giardina reported on failures in the diagnostic process that can be systematically used to monitor diagnostic safety concerns and identify opportunities for learning and improvement.
      • Giardina TD
      • et al.
      Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
      The dynamic and often intense setting of emergency care may increase the risk of substandard patient assessment. Therefore, awareness has to be raised in comparing results across the studies, and differences in clinical settings and populations must be taken into account. Systemic modifications and planned follow-ups have been suggested to provide further support to emergency care clinicians in an attempt to avoid diagnostic errors.
      • Hussain F
      • et al.
      Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
      ,
      • Moonen PJ
      • et al.
      Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.
      Harm hot spots are defined as areas containing complaints of major or catastrophic nature. Although harm and severity should be seen as independent factors according to the HCAT coding taxonomy,
      • Reader TW
      • Gillespie A
      • Roberts J.
      Patient complaints in healthcare systems: a systematic review and coding taxonomy.
      they appear to be correlated (confimed by pairwise correlation test 0.23 [p < 0.05]), as most harm hot spot complaints were either of medium or high severity. This may reflect the predefined criteria for injury compensation, in which patients are encouraged to file incidents of a certain severity, most of which fall within the clinical domain; this could contribute to the low prevalence of hot spot harm cases in the communication category (n = 9). Health care users’ dissatisfaction with care expressed through malpractice complaints is not always related to major or catastrophic harm. However, it is possible that complaint cases concerning communication are underrepresented in this sample.
      Most harmful hot spot cases were not directed at a specific profession, thus cases causing massive harm appear not to be related to a single staff member. Best practice policies and educational programs to avoid such harm hot spots should focus on causes of communication problems in emergency care, practices of patient-centered care, clear and consistent knowledge transfer, learning from diagnostic errors, and lowering the patient-to-clinician ratio.
      In line with earlier findings,
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      we found few cases categorized as hot spot near misses. They were generally coded in the same category as harm hot spots, indicating an overlap of harm and near-miss hot spots, and were predominantly in the quality category. Gillespie and Reader detected a wider distribution, as they also found near misses in the safety, institutional processes, and environment categories. We speculate that near-miss hot spot cases could develop into harmful hot spot cases and thus provide an opportunity to learn why an event did not lead to harm. Such knowledge may be useful to prevent further harm hot spot cases. We suggest that clinical departments monitor complaints to see if our study's findings apply to their setting.
      We found few (n = 17) entry/exit blind spots, or blind spots relating to stages either before/during admission or during/after discharge. This contrasts with the UK study,
      • Gillespie A
      • Reader TW.
      Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
      in which 32% of problems occurred at entry or exit. This difference is possibly due to the UK sample including other care settings besides emergency care. Further, there might be a selection of filed claims based on harm and severity level in our cohort of compensation claims. Therefore, we might find fewer entry/exit blind spot cases compared to studies including cases from various settings.
      Many (44.9%) of the errors of omission blind spots were related to neglect in general, in line with Reader and Gillespie.
      • Reader TW
      • Gillespie A.
      Patient neglect in healthcare institutions: a systematic review and conceptual model.
      General neglect covers failures of health care staff to achieve objective standards of care and behaviors that lead patients to think staff are uncaring. This relates closely to the concept of health care quality in the eyes of many health care users and might explain the relatively high percentage of cases of this type. A 2013 systematic review showed that patients reported neglect more often than clinicians,
      • Reader TW
      • Gillespie A.
      Patient neglect in healthcare institutions: a systematic review and conceptual model.
      suggesting that the meaning of neglect is perceived differently and that definitions are unclear. Further, a 2021 study found only a 7.6% overlap between patient complaints and staff reports of unsafe care, emphasizing the importance of analyzing and including patient complaints to ensure the patient perspective.
      • Van Dael J
      • et al.
      Getting the whole story: integrating patient complaints and staff reports of unsafe care.
      The results of these studies also demonstrate the need for improved definitions and articulation of the concept of neglect in complaints and staff reports.

      Strengths and Limitations

      Although we used compensation claim cases for the current study, the HCAT was developed for all kinds of complaints, including nonmonetary disciplinary complaints.
      • Gillespie A
      • Reader TW.
      The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.
      Different complaint types may be associated with different patterns of problems. Specifically, as indicated above, the patient compensation system may particularly attract complaints regarding actualized harm meriting injury compensation (rather than potential harm and near misses warranting no compensation), and we therefore may expect such cases to be underrepresented in our material. Future studies including nonmonetary complaints are therefore merited to establish the generalizability of our findings and supplement the picture of patient complaints about emergency care.
      For coding purposes, we used the original HCAT coding matrix developed in the UK.
      • Reader TW
      • Gillespie A
      • Roberts J.
      Patient complaints in healthcare systems: a systematic review and coding taxonomy.
      The HCAT taxonomy has been translated into Danish and was found to have good intra- and inter-rater reliability for categorizing problem types in Danish patient compensation claims.
      • Morsø L
      • et al.
      Quantification of complaint and compensation cases by introducing a Danish translated and cross-cultural adapted edition of the Healthcare Complaints Analysis Tool.
      ,
      • Bogh SB
      • et al.
      Healthcare Complaints Analysis Tool: reliability testing on a sample of Danish patient compensation claims.
      We found some minor discrepancies between the UK and Danish versions in terms of patient/relative involvement and hospital-acquired infections. Still, we do not believe that these have influenced the results of the current study. We recommend that future Danish studies use the HCAT-DK version, however, and that the Danish version is further adapted to the Danish health care setting.
      • Morsø L
      • et al.
      Quantification of complaint and compensation cases by introducing a Danish translated and cross-cultural adapted edition of the Healthcare Complaints Analysis Tool.
      Our raters were academics who were trained in the use of HCAT, and they completed their certification before assessing the study cases. They were required to code strictly according to the complaint letter and to avoid interpretations, and we are confident that the coding is valid.
      The implications of using systematic coding in complaint cases are several. First, the current individual handling of complaint cases leaves less room for organizational learning from these cases. Applying systematic coding allows organizations to use the complaint patterns to plan broader strategies to improve patient safety. Second, revealing areas of blind spots allows stakeholders to address challenges they had been unaware existed. Systematic coding also affects uncensored patient involvement through the use of patient complaint letters to code the complaint cases.

      Conclusion

      We applied the HCAT taxonomy to a national sample of compensation claims from emergency care and found that cases causing patient harm were most frequent at the examination and diagnosis stage of care rather than during admission, ward care, and procedures. Harm cases mostly related to the clinical domain (for example, diagnostic errors and undesirable outcomes) as opposed to relationship and management domains. From the perspective of future health care harm prevention, there seems to be a strong incentive to further analyze the amount and nature of diagnostic errors in emergency care and how to prevent them. Potential harm cases were mostly related to inadequate communication, particularly during patient discharge and transfers. Further, systemic blind spots were significantly associated with a greater number of complaint categories coded from the patient's complaint letter. The systematic coding and analytic approach of HCAT appear to be useful in detecting harm hot spots and blind spots in emergency care and directing attention toward specific aspects of care that might be improved through practice modifications and educational programs.

      Funding

      This work was supported by Region of Southern Denmark (17/33854). The funding source did not have involvement in the study at any time.

      Acknowledgments

      The authors would like to thank the two academic HCAT (Healthcare Complaints Analysis Tool) raters in the study, Kathrine Prisak Jakobsen and Jonas Harder Kerring.

      Conflicts of Interest

      All authors report no conflicts of interest.

      Appendix. Supplementary materials

      References

        • Gallagher TH
        • Mazor KM.
        Taking complaints seriously: using the patient safety lens.
        BMJ Qual Saf. 2015; 24: 352-355
        • Morsø L
        • et al.
        Quantification of complaint and compensation cases by introducing a Danish translated and cross-cultural adapted edition of the Healthcare Complaints Analysis Tool.
        Risk Manag Healthc Policy. 2021 Mar 29; 14: 1319-1326
        • Gillespie A
        • Reader TW.
        The Healthcare Complaints Analysis Tool: development and reliability testing of a method for service monitoring and organisational learning.
        BMJ Qual Saf. 2016; 25: 937-946
        • Wallace E
        • et al.
        Characterising patient complaints in out-of-hours general practice: a retrospective cohort study in Ireland.
        Br J Gen Pract. 2018; 68: e860-e868
        • Gillespie A
        • Reader TW.
        Patient-centered insights: using health care complaints to reveal hot spots and blind spots in quality and safety.
        Milbank Q. 2018; 96: 530-567
        • Reader TW
        • Gillespie A
        • Roberts J.
        Patient complaints in healthcare systems: a systematic review and coding taxonomy.
        BMJ Qual Saf. 2014; 23: 678-689
        • Birkeland S
        • et al.
        Changes in compensation claim contents following reorganization of emergency hospital care.
        Int J Qual Health Care. 2020 Dec 15; 32: 685-693
      1. Bekendtgørelse af lov om klage- og erstatningsadgang inden for sundhedsvæsenet995/2018. [Executive Order of the Act on Access to Complaints and Compensation in the Health Service 995/2018]. Jun 14, 2018. Accessed Feb 9, 2022. https://www.retsinformation.dk/eli/lta/2018/995.

        • Tilma J
        • et al.
        No-fault compensation for treatment injuries in Danish public hospitals 2006-12.
        Int J Qual Health Care. 2016; 28: 81-85
        • Birkeland S
        • et al.
        Healthcare inequality in compensation claims concerning acute hospital services: a Danish register-based study.
        Int J Qual Health Care. 2021 Feb 20; 33: mzaa163
        • Schnitzer S
        • et al.
        Complaints as indicators of health care shortcomings: which groups of patients are affected?.
        Int J Qual Health Care. 2012; 24: 476-482
        • Birkeland S
        • et al.
        Patient complaint cases in primary health care: what are the characteristics of general practitioners involved?.
        Biomed Res Int. 2013; 2013807204
        • Harrison R
        • et al.
        Patient complaints about hospital services: applying a complaint taxonomy to analyse and respond to complaints.
        Int J Qual Health Care. 2016; 28: 240-245
        • Bogh SB
        • et al.
        Healthcare Complaints Analysis Tool: reliability testing on a sample of Danish patient compensation claims.
        BMJ Open. 2019 Nov 25; 9e033638
        • Tilma J
        • et al.
        Existing data sources for clinical epidemiology: the Danish Patient Compensation Association database.
        Clin Epidemiol. 2015 Jul 17; 7: 347-353
        • Hussain F
        • et al.
        Diagnostic error in the emergency department: learning from national patient safety incident report analysis.
        BMC Emerg Med. 2019 Dec 4; 19: 77
        • Moonen PJ
        • et al.
        Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic.
        Scand J Trauma Resusc Emerg Med. 2017 Feb 14; 25: 13
        • Singh H
        • et al.
        Types and origins of diagnostic errors in primary care settings.
        JAMA Intern Med. 2013 Mar 25; 173: 418-425
        • Giardina TD
        • et al.
        Learning from patients’ experiences related to diagnostic errors is essential for progress in patient safety.
        Health Aff (Millwood). 2018; 37: 1821-1827
        • Giardina TD
        • et al.
        Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.
        BMJ Qual Saf. 2021; 30: 996-1001
        • Reader TW
        • Gillespie A.
        Patient neglect in healthcare institutions: a systematic review and conceptual model.
        BMC Health Serv Res. 2013 Apr 30; 13: 156
        • Van Dael J
        • et al.
        Getting the whole story: integrating patient complaints and staff reports of unsafe care.
        J Health Serv Res Policy. 2022; 27: 41-49