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Abstract
Introduction Patient safety is a high priority in the Danish health care system, including that hospital patients get the proper nutrition during their stay. A Nutrition Committee at Odense University Hospital is responsible for policy regarding nourishment at the hospital. If patients experience suboptimal treatment, i.e. improper nourishment, in the Danish health care system, they have the right to file a complaint. These complaints enable the improvement potentials based on the patients’ first hand experiences. Therefore, our aim was to examine the nutrition complaint pattern and to get a deeper understanding of the context surrounding nutrition problems, allowing the extraction of learning potentials.
Methods We analysed complaints submitted to Odense University Hospital between 2018 and 2022 using the Healthcare Complaint Analysis Tool. The complaints were categorised into categories, levels of severity and overall patient harm. The complaints containing a high-severity nutrition problem were read through and thematised into aspects not defined in the Healthcare Complaint Analysis Tool.
Results Between 2018 and 2022, 60 complaint cases containing 89 nutrition problems were filed to Odense University Hospital. Most (58.3%) of these were filed by the patients’ relatives. The nutrition problems were mostly of low severity (56.2%), while 23.6% were severe, and 20.2% were very severe. The reading of 18 very severe nutrition complaints revealed a cascade of problems triggered by the nutrition problem in six cases. Moreover, we saw that two high-severity nutrition problems led to catastrophic harm.
Discussion A low proportion of nutrition problems may express an underestimation regarding nourishment at the hospital. A patient’s threshold may not be exceeded by suboptimal nutrition and therefore does not file a complaint. However, complaints contain important insights contributing to wider learning, given that improvements at the hospital so far are based on clinicians’ reporting, overlooking the patient perspective.
- Patient safety
- Healthcare quality improvement
- Patient Rights
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Introduction
Patient safety is a high priority in the Danish healthcare system,1 where timely treatment is crucial for the patients’ outcomes. Among other things, nutrition and hydration influence how the patients’ course proceeds.2–4 Odense University Hospital (OUH) has a Nutrition Committee overseeing policy and nutrition standards,5 incorporating feedback from clinicians and learning of adverse events. However, the nutrition concerns the patients, so should we not learn from the patients’ perspective? Two systematic reviews showed that patients’ experiences of hospital nutrition were examined using various methods but they did not include patient complaints.6 7 Patient complaints, as formal letters expressing unbiased patient perspectives, provide readily available data within existing practice. When assessing patients’ complaints, we can display the proportions of nourishment problems from the patients’ viewpoint. A meeting with the Nutrition Committee caught an interest in going deeper into the nutrition complaints to gain insight into possible learning potentials. Therefore, the primary aims of this research paper were to examine the complaint patterns, assess the severity of the harm caused by the nutrition problems and gain a deeper contextual understanding of the context surrounding these problems, to extract valuable insights into learning opportunities.
Methods
Complaints submitted by patients at OUH between 2018 and 2022 were included. The complaints included letters filed to the Danish Patient Compensation, the Danish Patient Complaints Agency and emails filed directly to OUH. We accessed the complaints through the hospital filing system. According to Danish law, approvals were attained through the executive board at OUH.
The complaints were analysed using the Healthcare Complaint Analysis Tool (HCAT), a taxonomy for analysing reported problems in patient complaint letters.8 Through HCAT, the reported problems in each complaint letter were categorised into predefined categories, levels of patient-perceived severity and stages of care. One predefined category is nutrition, under which all complaints regarding nutrition issues are coded. The levels of severity include low (eg, isolated lack of food/water), medium (eg, nothing to eat/drink for one day) and high (eg, dehydration/malnourishment). Moreover, we coded the overall harm caused to the patient. HCAT has been tested valid and reliable in several studies.8–10 We made a content analysis of the high-severity complaints, thematising them on themes of interests aroused by the Nutrition Committee and complainants’ descriptions, thereby gaining an in-depth insight into potential aspects not defined in the HCAT categories.
Results
We identified 60 complaint cases containing 89 nutrition problems, with 58.3% (n=35) filed by patients’ relatives. Five complaints contained no other problem than suboptimal nutrition. On average, each case included 5.6 problems. The majority (56.2%, n=50) of the nutrition problems were less severe, while 23.6% (n=21) were severe and 20.2% (n=18) were very severe. Figure 1 illustrates the severity levels distributed across care stages, highlighting that most nutrition problems occurred on the ward. Additionally, 31.7% (n=19) of the complainants reported catastrophic harm (chronic damage or death) due to the patient’s hospital treatment.
Severity levels of nutrition problems distributed on which stage of care the nutrition problem occurred. Patients at OUH have reported 89 nutrition problems in 60 complaint letters between 2018 and 2022.
The content analysis of the 18 ‘high severity’ nutrition problems revealed additional insights into the contextual aspects and the harm caused. The average age of the affected patients in the 18 cases was 71 years. Four key findings encompassed: (1) identification of suboptimal nutrition as the central problem in five cases; (2) busyness as a contributing factor in four cases; (3) the harm caused by the nutrition problem, with two cases leading to catastrophic harm; and (4) observation of a cascade effect triggered by suboptimal nutrition in six cases. In one tragic case, a patient’s severe dehydration due to suboptimal nourishment ultimately resulted in organ failure, which proved fatal.
Discussion
The nutrition complaints filed to OUH accounted for 1% of all complaints. Few solely focused on nutrition (five cases), suggesting that complainants mainly file a nutrition problem when already filing a complaint for other reasons. These findings potentially express an underestimation regarding nutrition, probably because a nutrition problem rarely exceeds the threshold for filing a complaint. Patients may not be aware of how nutrition influences their illness. Most complaints seem to concern fragile patients, since most are elderly and relatives file their complaints. Though nutrition complaints centre around the elderly, an underestimation in this patient group might still occur. Suboptimal nutrition might be only one of several quality problems affecting the elderly. Therefore, nutrition might not be the focus if things go wrong. In contrast, the underestimation for young and healthier people may be explained by better overall recovery, so they might not complain about nutrition.
Although nutrition problems seem minor in complaints, they contain essential aspects once you look into them, as the complaints reveal the importance of proper nourishment to avoid the risk of cascading problems. A study found only an 8% overlap between complaints and staff-reported incidents,11 indicating different perspectives between patients and staff. While staff experience treatment errors, patients experience treatment omissions.12 Staff, therefore, might not report missing nourishment, although this mistreatment detects important improvement potentials. This study addresses a literature gap by examining complaint data, a resource previously overlooked in investigations on hospital nutrition. It sheds light on patient concerns already accessible within the hospital’s data infrastructure, a facet not explored in previous systematic reviews.6 7 This study’s limitation includes only reading ‘high severity’ complaints, overlooking nuances from less severe nutrition problems. Additionally, the generalisability of the results is constrained by limited data on nutrition problems and the inclusion of only one hospital in the study.
What can we learn?
Healthcare quality improvement largely relies on staff-reported incidents despite patients undergoing treatment and its potential consequences. By coding patient complaints systematically, we can highlight clusters of problems (eg, nutrition problems), revealing improvement potentials. Instead of handling the cases individually, examining the problems across complaint cases can guide decision-making, for example, increased focus on nutrition. Periodically analysing complaint data allows for assessing the effectiveness of improvement over time. This study has shown that the overview of complaint data provided a solid foundation for investigating areas of interest in depth. It proved a useful source for complementing everyday practice, especially when the Nutrition Committee sought to explore the areas that needed improvement. Hospital culture and procedures are often internal among staff, while patients, as external actors, experience their stay from a unique perspective, having first-hand exposure to the treatment process. Therefore, this approach offers insight beyond staff-reported incidents, offering a broader perspective and potentially enhancing treatment quality with previously undiscovered patient experiences.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
X @BieBogh, @Lars.Morsoe_dk
Contributors MKC, SBB and LM designed the study. MKC, SBB and LM collected the data. MKC processed and analysed the data. MKC, SBB, MSP and LM wrote and reviewed the manuscript. AI was used for supporting the English writing. The AI technology used was ChatGPT. As none of the authors' native language is English, AI was used for supporting the English writing as well as come up with suggestions for shorter phrases, as the paper needed to be shortened. The included suggestions from AI were carefully considered and were often further adjusted to fit into the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.