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What About the Patient? The Missing Partner in
Patient Safety
American Society for QualityQuality Management Division Conference
Dallas, TXMarch 5, 2004
Patrice L. Spath
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Patient Safety in Health Care
If not a crisis, certainly a loss of public confidence
The Public Is Concerned
1%6%
93%No
Yes Don’t know/ Refused
In the past 12 months, have you personally suffered personal injury or harm that you feel resulted from a medical error?
30%
32%
34%
40%
47%
47%
Percent who are “very concerned” about an error resulting in injury happening to them or their family…
When receiving health care in general
When going to a hospital for care
When going to a doctor’s office for care
When filling a prescription at a pharmacy
When flying on U.S. commercial airliners
When eating food 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)
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Traditional Performance Management Methods in Health Care
Competent physicians and staffPhysician credentialing/peer reviewStaff performance expectations
Well-defined systems and processesNotebooks full of policies and proceduresThe expectation that competent people should be able to it “right” every time
Performance measurement and quality improvement activities
The Result: Alarming Defect Rates
U.S. IndustryBest-in-Class
Outpatient antibiotics for colds
Post-MIβ-blockers
Breast cancerscreening (65-69)
Adverse drugevents
Hospital acquired infections
Hospitalized patientsinjured due to errors
1,000,000
100,000
10,000Defects
permillion
Airline baggage handlingDetection &treatment ofdepression
1,000Anesthesia-relatedfatality rate100
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(69%)2
(31%)3
(7%)4
(.6%)5
(.002%) (.00003%)6
σ level (% defects)
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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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National Focus on Patient Safety
Institute of Medicine report –“To Err is Human” (Nov. 1999)
44,000-98,000 deaths due to medical errorsAnnual 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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Initial Reactions
Distrust the data / challenge the definitions
Strengthen traditional methods to create safer systems and practices
Physician/staff trainingProcess improvement (RCA / FMEA)Gather and analyze incident data
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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)
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Vigilance Throughout the Continuum of Care
The patient is often the only “constant” in the continuum of care.
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Involve Patients & Their Families
Patients can help to reduce harmful mistakes
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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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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
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Another “Pair of Eyes” in the System
Remind caregivers to confirm their identityConfirm that caregivers know what the doctor orderedAsk caregivers to explain the reason for a test/treatmentVerify everyone knows what procedure is being doneAlert caregivers to unusual or unexpected events
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Do Patients Want to be Involved?
Range of responsesOstrich: “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.
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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.
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Patients as Safety Partners: A New Role
Change attitudes and behaviors of health care consumers
Consumers are safety partners in other industries
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Tapping into “Patient Power”
Role of organizations and practitioners
Open, honest communicationWillingness to partner with patients and their families
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Open, Honest Communication
Relevant JCAHO StandardsRI.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 safetyThe safe and effective use of medicationsSafe and effective use of medical equipment or supplies when provided by the organization
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Admit Mistakes Happen
“Everyone wants you to have a safe health care experience … here’s what you can do to help.”
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)
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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.”
Patient Education Tools
You will be reminded to do your breathing exercises. You can begin to drink clear liquids and eat when you feel you are ready.
You will need to arrive at the hospital 1 ½ hours before your scheduled surgery. A nurse will teach you about leg exercises and how to cough and take deep breaths after surgery.
Your doctor and Day Surgery nurse at the Hospital will explain the procedure to be done and your care after the surgery. You may need to have some tests done before your surgery.
The nurse will monitor your blood pressure, pulse, breathing, and temperature frequently. If you have any discomfort, ask your nurse for some medication. You should empty your bladder 4-6 hours after your surgery. If you can't empty your bladder or feel uncomfortable, tell your nurse. Your intravenous line will be removed when you are drinking enough fluids.
Your blood pressure, pulse, respirations, and temperature will be taken when you arrive. An intravenous line will be started in your vein and you will receive an antibiotic. You will be asked to empty your bladder 5 to 10 minutes before going to surgery.
A nurse from the Hospital's Day Surgery Unit will call you the day before surgery. They will tell you:•What time to arrive at the hospital;•Not to eat or drink anything the night before surgery;•What medications to take the night before or morning of surgery;•To have someone available to take you home.
Your physician or the surgical resident assisting him/her will see you before you are discharged.
An Anesthesiologist will talk with you and discuss the type of anesthesia to be used for your surgery.
Your doctor will do a Medical History and Physical and have you sign a form giving him/her permission to do surgery.
AFTER SURGERYBEFORE SURGERYBEFORE ADMISSIONLaparoscopic Cholecystectomy
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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 typeMake 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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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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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
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Willingness to Partner
It’s not enough to have an organizational commitment to patient partnership … patient-caregiver interactions must support this commitment
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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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Enabling Attitudes and Actions
EngagedDetachedCollective responsibilityIndividual accountability
Interdependent relationship (patient is empowered)
Unilateral ownership of quality and safety (patient is dependent)
Shared learningMaster of knowledge and skills
The Collaborative Professional
The Paternalistic Professional
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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.
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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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Safe Havens
Patients and their families should know who to contact with concerns or questions (other than the direct caregiver)
Patient advocateCustomer 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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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?
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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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A Few Watchwords
Commit (organization & individual)Think multiplicityPersistMeasureOgden Nash: When you feel how depressingly slowly you climb, always remember: things take time.
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Everyone Has a Role inHealth Care Safety
Senior leaders & quality professionalsPhysicians & other independent licensed practitionersNurses & other caregiversPatients & their families
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Resource
“Partnering with Patients to Reduce Medical Errors” (Jan. 2004)American Hospital Association
(www.ahaonlinestore.com)
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Be SafeThank You
Patrice L. SpathBrown-Spath & AssociatesForest Grove, OR
Phone: 503-357-9185Internet: www.brownspath.comemail: [email protected]
