Article Title

Problematic Events in Critically Ill Patients: The Perspectives of Surrogate Decision-Makers

Publication Date



patient safety, qualitative


Background/Aims: Critically ill patients are particularly vulnerable to breakdowns in medical care due to the severity and complexity of their illness. Although many critically ill patients are unable to communicate or participate in their own care, their surrogate decision-makers (SDMs) are likely to have important insights regarding preventable problematic events that may occur in the intensive care unit (ICU). We describe the perspective of SDMs of critically ill patients with such events.

Methods: We enrolled SDMs of adult critically ill patients with respiratory failure in any of the 7 ICUs at a single tertiary medical center in central Massachusetts. Participating SDMs were contacted by telephone approximately 4 weeks after the patient’s discharge and screened for those who identify a problematic event. Problematic events are defined as something that “went wrong,” that could have been prevented, and that had a deleterious impact on the patient or SDM. Participants who identify an event that meets the above criteria were invited to undergo an in-depth qualitative interview.

Results: Of the 127 SDMs we approached for participation, 91 (72%) agreed to participate, and complete follow-up is available on 70 of the 91 participants (77%). Of those with complete follow-up, 43% (30 of 70) identified at least one eligible problematic event, with many SDMs identifying multiple events. Problematic events included breakdowns in medical care (delay in diagnosis, misdiagnosis, delayed or inadequate treatment, preventable complications, and premature discharge) and major lapses in communication (insufficient information, inadequate access to health care providers, problems with communication regarding end-of-life preferences, and episodes of rude or dismissive treatment by health care providers). These problems had a significant negative impact on patients and their families leading to physical harm, prolonged hospitalization, rehospitalization, severe emotional distress, life disruption, and provision of medical care inconsistent with patients’ wishes.

Discussion: SDMs frequently identify preventable problems in the care of critically ill patients with significant adverse consequences for both patients and SDMs. These findings highlight the importance of the perspective of SDMs of critically ill patients in understanding breakdowns in care and may identify targets for preventing such events.




March 30th, 2015


April 28th, 2015