title: The tip of an iceberg? A cross-sectional study of the general public's experiences of reporting healthcare complaints in Stockholm, Sweden.
abstract: Objectives To investigate the hypothesis that complaints of adverse events related to encounters with healthcare personnel are underreported and to identify barriers to filing such complaints.  Design A cross-sectional study, where a questionnaire was sent to the respondents asking whether or not they have filed complaints of adverse events. Respondents were also asked whether they have had reasons for doing so but abstained, and if so their reasons for not complaining. The authors also asked about participants' general experience of and trust in healthcare.  Setting The County of Stockholm, Sweden.  Participants A random sample of 1500 individuals of the general population registered by the Swedish National Tax Board as living in the County of Stockholm in April 2008. Of the selected group, aged 18-99 years, 50% were women and 50% men. Response rate was 62.1%, of which 58% were women and 42% were men; the median age was 49 years.  Primary and secondary outcome measures Primary outcome measures were whether the participants have filed a formal complaint with the Patients' Advisory Committee and whether they have had reason to file a complaint but have refrained from doing so. Secondary outcome measures were the participants' general experience of and trust in healthcare.  Results Official complaints have been filed by 23 respondents (2.7%, 95% CI 1.7% to 3.7%), while 159 (18.5%, 95% CI 15.9% to 21.1%) stated that they have had legitimate reasons to file a complaint but have abstained (p<0.001). The degree of under-reporting was greater among patients with a general negative experience of healthcare (37.3%, 95% CI 31.9% to 42.7%) compared with those with a general positive experience (4.8%, 95% CI 2.4% to 7.2%). The reasons given for abstaining were, among others, 'I did not have the strength', 'I did not know where to turn' and 'It makes no difference anyway'. Respondents with a general negative experience also had lower trust in healthcare.  Conclusions The authors found a considerable discrepancy between the actual complaint rate and the number of respondents stating that they have had reasons to complain but have abstained. This indicates that in official reports of complaints, the authors only see 'the tip of an iceberg'.
authors.affiliation: Learning, Informatics, Managements and Ethics (LIME), Stockholm Centre for Healthcare Ethics (CHE), Stockholm, Sweden.
authors.forename: Maja
authors.initials: M
authors.lastname: Wessel
authors.forename: Niels
authors.initials: N
authors.lastname: Lynøe
authors.forename: Niklas
authors.initials: N
authors.lastname: Juth
authors.forename: Gert
authors.initials: G
authors.lastname: Helgesson