Patient complaints in radiology: 9-year experience at a European tertiary care center

This retrospective study was approved by the local ethics committee (IRB number: 201800207) and the requirement for informed consent was waived. The University Medical Center Groningen is a tertiary care center that provides primary and specialty care to over two million people in the northeast of the Netherlands. The department of radiology has a digital archive in which all written patient complaints (both e-mails and letters, whether from the patients themselves, their relatives, or other representatives) are stored that were received within a consecutive 9-year period (January 2010 to December 2018). According to the institutional protocol, all written patient complaints are received by or should be forwarded to the independent complaints officer. Each complaint is then sent to the head(s) of the department(s) involved, who in turn respond(s) with a letter directed to the patient via the complaints officer. Complaints received by another department which include issues relevant to radiology are passed on to the head of the department of radiology. All patient complaint letters were included for analysis in this study, except if the complaint was not related to a procedure that was performed at the department of radiology, or if it was unclear if this was the case. Financial compensation was given for travel costs, hotel stay (for patients who had to travel from far away for a radiological procedure that was scheduled early in the morning), and missed income on the day of the radiological procedure, upon specific request by the patient and if considered justified by the head of the department of radiology.

All patient complaints were unsolicited and in non-standardized formats. A research fellow (P.F.v.d.B.) reviewed all patient complaints to retrieve the year in which the complaint was filed, age and gender of the patient, patient’s hospital status (inpatient, outpatient, or emergency department), type of radiological procedure (conventional radiography, fluoroscopy (performed by non-interventional radiologists outside the dedicated interventional radiology suite), ultrasonography, CT, MRI, or interventional radiology), specialty of the primary treating physician(s), if the complaint was solely directed to the department of radiology or if it was also directed to other departments (i.e., shared complaint), and whether or not a financial compensation was given by the hospital. All complaints were analyzed and interpreted using standardized coding taxonomy that was recently developed by Reader et al [7] (Table 1). This coding taxonomy for patient complaints uses three domains: “clinical” (complaints on the safety and quality of clinical care), “management” (complaints related to the management of the healthcare organization), and “relationships” (complaints about healthcare staff-patient relationships) [7]. The clinical domain is divided into the categories “quality” and “safety,” the management domain is divided into the categories “institutional issues” and “timing/access,” and the relationships domain is divided into the categories “communication,” “humaneness/caring,” and “patient rights” [7]. Categories are further divided into 26 subcategories, which are described in detail by Reader et al [7]. One complaint letter can contain multiple domains, categories, and subcategories. Subsequently, the severity of each complaint category was classified as “low,” “medium,” or “high,” according to Gillespie et al [8]. Note that severity ratings are independent of outcomes (i.e., harm) and not comparable across problem categories [8]. If one complaint letter contained different complaint categories with different severity ratings, the highest level of severity was recorded [8].

Characteristics of patients who filed the complaints; specialty of the primary treating physician(s); sharing of complaints with other departments; distribution of complaints among the different domains, categories, and subcategories according to Reader et al [7]; severity of complaints according to Gillespie et al [8]; and financial compensation were descriptively analyzed. Frequencies of complaints per type of radiological procedure were compared using a chi-square test with the Bonferroni correction. The presence of a temporal trend of complaint frequencies over the years was assessed using the Mann-Kendall test. Complaint frequencies were only analyzed for the years 2010 to 2017, because the hospital deployed a new electronic medical record software application in 2018, from which reliable production numbers could not yet be extracted. P values less than 0.05 were considered statistically significant. Statistical analyses were performed using R version 3.5.2 software (R Foundation for Statistical Computing).

A total of 96 complaint letters were submitted between January 2010 and December 2018.

Two complaint letters were excluded, because it was uncertain if they were related to a procedure that was performed at the department of radiology (both complaint letters were related to the placement of a central venous catheter without any record that this procedure was performed at the department of radiology). The 94 remaining complaint letters that were finally included concerned 44 male patients, 49 female patients, and 1 patient whose gender remained unclear, with a mean age of 48 ± 22.0 years (range, 6 months–79 years). Sixty-one (64.9%) of patients’ complaints were related to an outpatient setting, 22 (23.4%) to an inpatient setting, and 11 (11.7%) to an emergency department setting. Sixty-two (66%) of these complaints were filed by patients themselves, 17 (18.1%) were filed by family members, 8 (8.5%) were received through the Prevention Recovery Information System for Monitoring and Analysis (PRISMA)-Medical method [9], 4 (4.3%) were filed by other medical doctors, and 3 (3.2%) were filed by the partner of the patient. Treating specialty was most frequently surgery (19.1%), followed by orthopedics (12.8%) and emergency medicine (10.6%). Fifty-one (54.3%) of complaints were shared with other departments, and 43 (45.7%) were solely directed to the department of radiology. The department of surgery was most frequently involved in a shared complaint (33.3%), followed by the departments of orthopedics (17.6%) and pediatrics (15.7%).

Eighty-nine complaint letters were filed between 2010 and 2017, in which a total of 618,482 radiological procedures were performed, corresponding to an overall complaint frequency of 14.4 per 100,000 radiological procedures. Frequencies of complaints per 100,000 procedures were, in order of decreasing frequency, 103.7 (95% confidence interval [CI], 74.6–144.2) for interventional radiology, 13.9 (95% CI, 9.0–21.5) for MRI, 6.9 (95% CI, 3.9–12.0) for ultrasonography, 6.5 (95% CI, 3.8–11.1) for CT, 4.5 (95% CI, 1.2–16.2) for fluoroscopy, and 1.2 (95% CI, 0.7–2.1) for conventional radiography (Fig. 1). Interventional radiology received significantly more complaints than all other radiological procedures (p < 0.001). All cross-sectional imaging modalities (CT, MRI, and ultrasonography) also received significantly more complaints than conventional radiography (p < 0.001). Other complaint frequencies did not differ significantly from each other (Table 2).

Figure 2 shows the distribution of complaints among the different domains, categories, and subcategories according to the patient complaint taxonomy by Reader et al [7]. Fifty-three (56.4%) of complaints belonged to the clinical domain, 22 (23.4%) to the relationships domain, and 19 (20.2%) to the management domain. Quality (34.0%), safety (22.3%), timing and access (18.1%), and communication (18.1%) constituted almost all complaint categories. Patient journey (19.1%), delays (18.1%), communication breakdown (16.0%), errors in diagnosis (11.7%), quality of care (9.6%), treatment (6.4%), and staff attitudes (2.1%) accounted for almost all complaint subcategories. Complaint severity ratings were low, medium, and high, in 44 (46.8%), 28 (29.8%), and 22 (23.4%) of complaints, respectively.

Figure 3 shows the annual frequencies of complaints that were filed. Between 2010 and 2017, the annual frequency of complaints decreased over time with a Mann-Kendall tau of − 0.429, but this did not reach statistical significance (p = 0.174).

Financial compensation was granted in 8 (8.5%) cases. Data regarding the amount of financial compensation was available in 5 of 8 cases. The mean financial compensation in these 5 cases was €94.69 ± 93.41 (range, €35.00–€253.46).

An example of a high-severity complaint concerned a 37-year-old woman who underwent an interventional radiology procedure (sclerotherapy) for the treatment of an arteriovenous malformation in the right lower arm. After treatment, she developed intense and increasing pain. Before, during, and after the treatment, the communication with the treating staff was experienced as poor.

An example of a low-severity complaint concerned a 47-year-old man who was supposed to undergo a CT scan of the abdomen because of autoimmune hepatitis, before his annual checkup at the department of gastroenterology. However, due to poor communication and planning, it was not possible to perform the CT scan before the checkup, as a result of which the value of the consultation with the gastroenterologist was experienced as considerably diminished.