242 Harm is harm: incorporating the patient experience of avoidable harm in the science of investigation

Introduction There is a global call to learn from patient experiences of avoidable harm for healthcare improvement. However, a paradigm shift is required. Healthcare organizations must expand their understanding of avoidable harm beyond the historical focus on physical harms. At University Health Network (UHN) - a large multisite academic health science centre in Canada - a multi-disciplinary working group recognized the need for an expanded definition of avoidable patient harm where harm goes beyond physical harms and includes non-physical harms (NPH).We define NPH as: event(s) causing damaging effects to an individual’s dignity or their emotional, psychological, social, or spiritual health.Intervention Using quality improvement methods, a learning response framework to identify, analyse and learn from avoidable physical and non-physical patient harms was co-designed and integrated into existing patient safety reporting and learning process. Focus groups with patient partners, and leaders, were conducted to determine the required resources to learn from patient experiences of NPH. Results informed the development of a framework, including scoring matrix, and toolkit for implementation. Further, de-identified feedback cases were reviewed and screened using the proposed matrix, with level of agreement from 10 reviewers analysed to inform the iterative improvement of the matrix. Understanding of NPH by impacted leaders and teams was assessed using a pre/post knowledge survey. Additionally, the rate of NPH cases is tracked to monitor and inform improvement.Results Focus groups conducted with patent partners on processes for reporting and reviewing NPH revealed several potential patient priorities, including: the need for a patient-facing NPH reporting form, an anonymous reporting option, increased psychological safety in sharing experiences, and increased awareness/visibility of the reporting process and potential outcomes. Focus groups with leaders revealed several anticipated gaps, including: an accepted definition of NPH, a process to identify and review NPH incidents, role clarity in the review process, and communication strategies for team engagement with this new concept. Also articulated was the need for a leadership toolkit to support operationalization, and standardized education for reporting and review of NPH. Based on these focus groups, the NPH framework launched across the organization in April 2024, and included: a co-designed definition, screening matrix for consistent case identification; and analysis resources. A leadership toolkit was also launched, and included: NPH definition, supportive resources to discuss NPH with teams; and tools for identification and review of NPH cases. Pre/post knowledge survey conducted with impacted leaders and teams demonstrated an increase in NPH knowledge post framework deployment across all groups (leaders=13%, Patient Relations=13%, Patient Safety= 30%), with reasonable response rates (Leaders pre n=98, post n=54; Patient Relations: pre n=6, post n=5; Patient Safety: pre n=6, post n=6).Conclusion Incorporating a broad view of avoidable patient harm in incident reporting and learning adds to the science of incident investigation. The involvement of patient partners was critical in the development of the of the screening matrix, as well as processes for reporting NPH that were responsive to, and considered patient needs, including psychological safety in the reporting process. The lessons learned from NPH cases identified and reviewed since launch of the framework will continue to inform improvements reflective of what matters most to our patients. Additionally, this framework supports responding to patient experiences of care and their expressed need for improved healthcare outcomes.

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