title: Surrogate decision makers' perspectives on preventable breakdowns in care among critically ill patients: A qualitative study.
abstract: To describe surrogate decision makers' (SDMs) perspectives on preventable breakdowns in care among critically ill patients.
  
  
  
  We screened 70 SDMs of critically ill patients for those who identified a preventable breakdown in care, defined as an event where the SDM believes something "went wrong", that could have been prevented, and resulted in harm. In-depth interviews were conducted with SDMs who identified an eligible event.
  
  
  
  32 of 70 participants (46%) identified at least one preventable breakdown in care, with a total of 75 discrete events. Types of breakdowns involved medical care (n=52), communication (n=59), and both (n=40). Four additional breakdowns were related to problems with SDM bedside access to the patient. Adverse consequences of breakdowns included physical harm, need for additional medical care, emotional distress, pain, suffering, loss of trust, life disruption, impaired decision making, and financial expense. 28 of 32 SDMs raised their concerns with clinicians, yet only 25% were satisfactorily addressed.
  
  
  
  SDMs of critically ill patients frequently identify preventable breakdowns in care which result in harm.
  
  
  
  An in-depth understanding of the types of events SDMs find problematic and the associated harms is an important step towards improving the safety and patient-centeredness of healthcare.
authors.affiliation: Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA; Meyers Primary Care Institute, 425 North Lake Avenue, Worcester, MA 01605, USA. Electronic address: kimberly.fisher@umassmemorial.org.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Fisher
authors.affiliation: Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
authors.forename: Sumera
authors.initials: S
authors.lastname: Ahmad
authors.affiliation: Meyers Primary Care Institute, 425 North Lake Avenue, Worcester, MA 01605, USA.
authors.forename: Madeline
authors.initials: M
authors.lastname: Jackson
authors.affiliation: Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA; Meyers Primary Care Institute, 425 North Lake Avenue, Worcester, MA 01605, USA.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Mazor
mesh_terms: D000328:Adult; D003142:Communication; D003266:Continuity of Patient Care; D016638:Critical Illness / Q000628:therapy; D003657:Decision Making; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007407:Interviews as Topic; D008297:Male; D008404:Massachusetts; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D061214:Patient Safety; D011368:Professional-Family Relations; D036301:Qualitative Research
keywords: Adverse events; Communication; Medical errors; Patient safety; Quality of healthcare