This document discusses engaging patients as partners in patient safety efforts. It notes that while traditional methods have focused on competent staff and well-defined systems, medical error rates remain alarming. The patient is often the only constant in their care, and can serve as an extra set of eyes to help catch potential mistakes. The document advocates educating patients on safety issues and their role, and empowering them with information to play a proactive role in reducing errors. It also acknowledges some patients may prefer a more passive role unless caregivers are supportive of their involvement.

1. What About the Patient?
The Missing Partner in
Patient Safety
American Society for Quality
Quality Management Division Conference
Dallas, TX
March 5, 2004
Patrice L. Spath

2. Patient Safety in Health Care
If not a crisis,
certainly a loss of
public confidence
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3. The Public Is Concerned
Percent who are “very concerned” In the past 12 months, have you
about an error resulting in injury personally suffered personal injury or
happening to them or their family… harm that you feel resulted from a
medical error?
When receiving
health care in general
47%
When going to
a hospital for care
47%
93%
When going to a
No
doctor’s office for care
40%
When filling a
prescription at a pharmacy 34%
6%
When flying on U.S. 1% Don’t know/
commercial airliners
32% Yes Refused
When eating food
30%
purchased at the supermarket
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality National Survey on Americans as Health Care
Consumers: An Update on The Role of Quality Information, December 2000 (Conducted July 31-Oct. 13, 2000)

4. Traditional Performance
Management Methods in Health Care
Competent physicians and staff
Physician credentialing/peer review
Staff performance expectations
Well-defined systems and processes
Notebooks full of policies and procedures
The expectation that competent people should
be able to it “right” every time
Performance measurement and quality
improvement activities
4

5. The Result: Alarming Defect Rates
Breast cancer Outpatient antibiotics for colds
screening (65-69)
1,000,000 Hospital acquired infections
100,000 Hospitalized patients
Post-MI injured due to errors
10,000 β-blockers
Defects Airline baggage handling
Detection &
per 1,000
treatment of Adverse drug Anesthesia-related
million 100 events
depression fatality rate
10 U.S. Industry
Best-in-Class
1
1 2 3 4 5 6
(69%) (31%) (7%) (.6%) (.002%) (.00003%)
σ level (% defects)

6. Mistakes Happen
Even the most competent
professionals can make a mistake
99.9% of the time health care
professionals are ‘set up’ to make a
mistake.
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7. National Focus on Patient Safety
Institute of Medicine report –
“To Err is Human” (Nov. 1999)
44,000-98,000 deaths due to medical errors
Annual cost $17B-$29B
Federal Mandate and Regulatory
Requirements
- Presidential directive, Joint Commission on
Accreditation of Healthcare Organizations,
Centers for Medicare & Medicaid Services,
State regulations
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8. Initial Reactions
Distrust the data / challenge the
definitions
Strengthen traditional methods to
create safer systems and practices
Physician/staff training
Process improvement (RCA / FMEA)
Gather and analyze incident data
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9. Patients – Players in the System
“The patient is one of the players in
the complex system of health care and
yet physicians and other health care
professionals often think of them in a
passive way as the victims of errors
and safety failures.”
Joel Mattison, M.D., F.A.C.S, Medical Director, Clinical
Resource Management, St. Joseph’s Hospital, Tampa, FL.
Author of chapter in “Partnering with Patients to
Reduce Medical Errors” (AHA Health Forum, 2004)
9

10. Vigilance Throughout the
Continuum of Care
The patient is
often the only
“constant” in the
continuum of care.
10

11. Involve Patients & Their Families
Patients can help
to reduce harmful
mistakes
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12. What Patients are Saying
Health care professionals should
remember that they are human and will
make mistakes. There is no harm in
checking with the patient or their family
members for a second opinion. And there
is no excuse for ignoring or trivializing
patient input.
Female, 45-years old, Texas. No health care
background. Cares for her husband who suffered
a stroke and renal failure 10 years ago.
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13. Patient Power
Patients can play an active part in
preventing some mistakes if given the
correct information and the right
tools for the job.
Environmental safety
Clinical safety
13

14. Another “Pair of Eyes” in the
System
Remind caregivers to confirm their
identity
Confirm that caregivers know what the
doctor ordered
Ask caregivers to explain the reason for a
test/treatment
Verify everyone knows what procedure is
being done
Alert caregivers to unusual or unexpected
events
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15. Do Patients Want to be Involved?
Range of responses
Ostrich: “It won’t happen to me. It’s not
my job to prevent medical mistakes.”
Passive: Wants to know how to prevent
mishaps, but won’t act unless caregivers
are supportive.
Assertive: Deliberately seeks out
information on how to prevent mistakes
and assumes a proactive role.
15

16. Marking Surgical Sites
Study of patient participation in surgery
site marking:
A surprisingly high number (35%) of patients
did not comply with the orthopedist’s request
to mark “NO” on the extremity that was not
to be operated on, even when patients were
told that such a mark was intended to
prevent wrong-site surgery.
DiGiovanni, C.W., Kang, L., Manuel, J. “Patient Compliance in
Avoiding Wrong-Site Surgery.” The Journal of Bone and Joint
Surgery (American), 2003, 85:815-819. 16

17. Patients as Safety Partners:
A New Role
Change attitudes and behaviors of
health care consumers
Consumers are safety partners in
other industries
17

18. Tapping into “Patient Power”
Role of organizations and
practitioners
Open, honest communication
Willingness to partner with
patients and their families
18

19. Open, Honest Communication
Relevant JCAHO Standards
RI.3.10 – Patients are given information about their
responsibilities while receiving care, treatment, and
services.
Mechanism for communicating responsibilities to
patients, including the responsibility to ask
questions
PC.6.10 – The patient is educated about:
Basic health practices and safety
The safe and effective use of medications
Safe and effective use of medical equipment or
supplies when provided by the organization 19

20. Admit Mistakes Happen
“Everyone wants you to have a safe
health care experience … here’s what
you can do to help.”
20

21. Safety Education Resources for Patients
National Patient Safety Foundation (www.npsf.org)
Joint Commission (www.jcaho.org)
Agency for Healthcare Research and Quality (www.ahrq.gov)
Institute for Safe Medication Practices (www.ismp.org)
American Academy of Orthopaedic Surgeons
(http://orthoinfo.aaos.org)
National Council on Patient Information and Education
(www.talkaboutrx.org)
The Minnesota Alliance for Patient Safety (www.mhhp.com)
Virginians Improving Patient Care and Safety (www.vipcs.org)
Madison (WI) Patient Safety Collaborative
(www.madisonpatientsafety.org)
Ohio Patient Safety Institute (www.ohiopatientsafety.org)
AORN Patient Safety First (www.patientsafetyfirst.org)
Sentara Healthcare (www.sentara.com/patientsafety)

22. Empower Patients with
Information
To serve as safeguards in the system,
patients must know what to expect
during the health care experience
“Your test results will be back within 7
days. If you don’t hear from my office
by the end of that time, please contact
us.”
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23. Patient Education Tools
Laparoscopic Cholecystectomy
BEFORE ADMISSION BEFORE SURGERY AFTER SURGERY
Your doctor will do a Medical An Anesthesiologist will talk with Your physician or the surgical
History and Physical and have you you and discuss the type of resident assisting him/her will see
sign a form giving him/her anesthesia to be used for your you before you are discharged.
permission to do surgery. surgery.
A nurse from the Hospital's Day Your blood pressure, pulse, The nurse will monitor your blood
Surgery Unit will call you the day respirations, and temperature will pressure, pulse, breathing, and
before surgery. They will tell you: be taken when you arrive. temperature frequently. If you
•What time to arrive at the An intravenous line will be started have any discomfort, ask your
hospital; in your vein and you will receive nurse for some medication. You
•Not to eat or drink anything the an antibiotic. You will be asked to should empty your bladder 4-6
night before surgery; empty your bladder 5 to 10 hours after your surgery. If you
•What medications to take the minutes before going to surgery. can't empty your bladder or feel
night before or morning of uncomfortable, tell your nurse.
surgery; Your intravenous line will be
•To have someone available to removed when you are drinking
take you home. enough fluids.
Your doctor and Day Surgery You will need to arrive at the You will be reminded to do your
nurse at the Hospital will explain hospital 1 ½ hours before your breathing exercises. You can
the procedure to be done and your scheduled surgery. A nurse will begin to drink clear liquids and eat
care after the surgery. You may teach you about leg exercises and when you feel you are ready.
need to have some tests done how to cough and take deep
before your surgery. breaths after surgery.

24. Incorporate Safety Topics into
Disease-Specific Education
In the “Diabetes – What You Need to Know”
educational booklet safety tips include:
Check the label on your insulin bottle to
be sure you have the correct type
Make sure your insulin syringe and insulin
bottle are marked with the same
concentration
Always read your labels
Source: Royal Oak Beaumont Hospital, Royal Oak, MI
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25. Teach Them What WE Know
How do YOU check that things are
going right when you or a loved one is
receiving medical care?
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26. Suggestions from a Surgeon
After he was hospitalized for surgery
Make yourself easily and instantly
recognizable and not just the patient in “B
bed.” Write your name in large letters on a
sign and place it by your bed.
Keep a small notepad and pencil at your
bedside to jot down thoughts that might
otherwise be lost during those temporary
memory lapses.
Joel Mattison, M.D., F.A.C.S, Medical Director, Clinical
Resource Management, St. Joseph’s Hospital, Tampa, FL 26

27. Willingness to Partner
It’s not enough to have an
organizational commitment to patient
partnership … patient-caregiver
interactions must support this
commitment
27

28. What Patients are Saying
Health professionals must understand
that I am also a member of the team.
Members of the team should be accessible
to me. Information should be shared with
me. I should be part of the process, not a
helpless victim.
Female, 59-years old, New York City. No
health care background. No chronic illness;
only occasional interaction with a physician.
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29. Enabling Attitudes and Actions
The Paternalistic The Collaborative
Professional Professional
Master of knowledge and Shared learning
skills
Unilateral ownership of Interdependent
quality and safety (patient relationship (patient is
is dependent) empowered)
Individual accountability Collective responsibility
Detached Engaged
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30. How to Stop Patients From
Speaking Up (more than once)
Deliberately change the subject because you are
uncomfortable.
Fail to clarify the patient’s concern.
Offer premature or inappropriate reasons or
answers.
Cite policy as the reason for an action.
Minimize or disregard the patient’s concern with
comments such as “Don’t worry; we’ve handled it.”
Make promises to do things you don’t or can’t
follow through on.
Blame or “put down” the organization.
30

31. What Patients are Saying
When you’ve got to be there all the time,
you don’t want to fall out with any nurse
or put any blame on anybody. Obviously,
all the nurses stick together. And,
hopefully, the same mistake won’t happen
again.
A person interviewed during a study of patients who
had used an infusion pump during a hospital stay
(Research conducted in early 2003 by the UK National
Patient Safety Agency).
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32. Safe Havens
Patients and their families should
know who to contact with concerns or
questions (other than the direct
caregiver)
Patient advocate
Customer service department
Printed on the patient safety brochure at Royal Oak
Beaumont Hospital, Royal Oak, MI:
Please tell us if you have questions or concerns about your care. You
are welcome to call our customer hotline: 248-551-2273
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33. Measure Partnership Efforts
During safety rounds, ask currently hospitalized
patients:
Have you noticed the staff asking you to state
your name or have they checked your
identification band?
Have you or your family had a chance to review
the information in the patient safety brochure?
If you had surgery, were you asked to mark
your surgical site? If so, what do you think
about that process?
Would you feel comfortable asking a doctor if
he had washed his/her hands before examining
you? 33

34. Safety-Related Survey
Questions
Did the health care worker spend
sufficient time reviewing your admission
packet?
Did you feel appropriately involved in your
care?
Were you encouraged to ask questions?
If there were any unplanned or
unanticipated events in your care, were you
kept informed in a timely and satisfactory
manner?
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35. A Few Watchwords
Commit (organization & individual)
Think multiplicity
Persist
Measure
Ogden Nash: When you feel how
depressingly slowly you climb, always
remember: things take time.
35

36. Everyone Has a Role in
Health Care Safety
Senior leaders & quality
professionals
Physicians & other
independent licensed
practitioners
Nurses & other caregivers
Patients & their families
36

37. Resource
“Partnering with Patients to Reduce
Medical Errors” (Jan. 2004)
American Hospital Association
(www.ahaonlinestore.com)
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38. Thank You Be Safe
Patrice L. Spath
Brown-Spath & Associates
Forest Grove, OR
Phone: 503-357-9185
Internet: www.brownspath.com
email: patrice@brownspath.com
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