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Communicating with patients about breakdowns in care: a national randomised vignette-based survey
  1. Kimberly A Fisher1,2,
  2. Thomas H Gallagher3,
  3. Kelly M Smith4,
  4. Yanhua Zhou2,
  5. Sybil Crawford1,2,
  6. Azraa Amroze2,
  7. Kathleen M Mazor1,2
  1. 1 Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
  2. 2 Meyers Primary Care Institute, a joint endeavor of the University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester, Massachusetts, USA
  3. 3 Department of Medicine, University of Washington, Seattle, Washington, USA
  4. 4 MedStar Institute for Quality and Safety, Columbia, Maryland, USA
  1. Correspondence to Dr Kimberly A Fisher, Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA; kimberly.fisher{at}


Background Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed.

Objective To identify factors which influence speaking up, and to examine the impact of apology when problems occur.

Design Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied.

Setting National online survey.

Participants 1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate.

Main outcomes and measures Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital.

Results Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not ‘definitely’ speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer’s role influenced speaking up for two of the three breakdowns (rudeness and slow response).

Conclusions Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients’ willingness to recommend the hospital.

  • health services research
  • healthcare quality improvement
  • communication
  • patient-centred care
  • patient satisfaction

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  • Contributors All of the authors are responsible for this research; all have participated in the concept and design, analysis and interpretation of data, drafting or revising the manuscript and have approved the manuscript as submitted.

  • Funding This study was funded by the Agency for Healthcare Research and Quality (4R18HS022757 and 1K08HS024596).

  • Disclaimer The funder had no role in the design, conduct or reporting of this study.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.