Surrogate decision makers’ perspectives on preventable breakdowns in care among critically ill patients: A qualitative study

•SDMs of critically ill patients frequently identify preventable breakdowns in care.•Types of breakdowns reported include problems with medical care and communication.•Breakdowns resulted in a variety of adverse consequences for patients and SDMs.•Healthcare providers often do not respond adequately to SDMs reports of breakdowns.

ObjectiveTo describe surrogate decision makers’ (SDMs) perspectives on preventable breakdowns in care among critically ill patients.MethodsWe 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.Results32 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.ConclusionSDMs of critically ill patients frequently identify preventable breakdowns in care which result in harm.Practice ImplicationsAn 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.