Since the watershed Institute of Medicine report on medical errors was released in 1999, hospitals have formed steering committees, added safety administrators and hired consultants in an effort to correct the systemic flaws that lead to medication errors and wrong-site surgeries.
Yet safety advocates say this work often is invisible to a key constituency: the patients. After all, the finished product is, one hopes, an event that never happens. The third annual Patient Safety Awareness Week (March 7-13) offers a prime opportunity for hospitals and systems to bring patients and their families into the fold.
"There's a real effort to get patients involved," says Timothy Flaherty, a radiologist from Neenah, Wis., and chairman of the National Patient Safety Foundation, or NPSF, which is organizing the event for the first time. "They have a responsibility to ask the right questions and provide the information that helps their physicians and nurses avoid errors."
This year's theme is "The Power of Partnership"-the one between provider and patient. Hospitals nationwide have planned a range of activities to take the safety mantra directly to their patients and into their communities.
The NPSF serves as a clearinghouse for dozens of ideas for activities and resources to mark the week. A few examples include:
* Setting up a one-week hotline for patients and staff to report safety concerns.
* Holding a roundtable discussion with staff, patients and families to discuss a specific safety issue.
* Distributing wallet cards for patients to record all their medications and phone numbers for doctors and pharmacies.
* Submitting staff-written op-ed pieces or first-person accounts about patient-safety issues to local newspapers.
At Iowa Health System in Des Moines, the chief medical officer will discuss with a local TV reporter how patients can help avoid medication errors and prevent accidental falls in hospitals. The spot will refer viewers to the station's Web site, ihsdesmoines.org, for more patient-safety information. Also this week, the healthcare system will recruit patients and family members to serve on newly formed patient advisory councils. The system's goal is to have one in place at each of its 11 hospitals by year-end. "It's critical that patients understand we need their viewpoints so that we can look at safety issues from a different perspective," says Gail Nielsen, the system's patient-safety administrator.
The consumer-centric focus is a sign that hospitals are embracing patient involvement as a critical step in the bridging the safety gap. The strategy dovetails with patient-education initiatives from groups such as the Agency for Healthcare Research and Quality and the Joint Commission on Accreditation of Healthcare Organizations.
Despite the key role patients play in this effort, it can be uncomfortable for them to ask a nurse to double-check the blood type or medication dose, says Ilene Corina, who founded Patient Safety Awareness Week in 2002.
Corina, whose 3-year-old son, Michael, died in 1990 after complications from a routine tonsillectomy, says highlighting patient-safety week should serve as an icebreaker for patients to start asking those tough questions.
"The idea is to set aside a week to get people talking about medical errors," says Corina, a foundation board member and co-president of Persons United Limiting Substandards and Errors in Health Care, which previously organized the event.
Corina says hospitals celebrating the week should keep a tight focus on the gritty details of medical-error prevention. During the past two years she's seen overblown safety campaigns that blur the mission by including a health fair with blood pressure screenings or wellness seminars, for example.
Also, organizers say at least some elements of the educational campaign should extend into the community, whether it's recording a TV show or handing out literature at a local mall.
The idea, Corina says, is to get across the message-before people end up in the hospital-that there are specific hospital staff members who can address safety concerns.
"Once you're in the hospital, all you know is your doctor or your nurse," Corina says. "You don't realize that there are other people to go to if there's a potential problem," such as a nurse supervisor, social worker, patient advocate or even a member of the ethics committee.
While the thrust of the week will be patient education, organizers say activities also should reinforce patient-safety protocols for hospital staff.
At Allen Memorial Hospital, an Iowa Health System facility in Waterloo, a contest has solicited firsthand staff accounts of near-miss medical errors-mistakes that were caught before any harm was done-which will be published in the hospital's internal newsletter. The healthcare system plans to make such "real life" mishaps a regular part of its patient-safety program.
"It doesn't take much to make that leap to a higher priority after you hear these real stories," Nielsen says.
For more information on Patient Safety Awareness Week, visit the NPSF Web site at npsf.org/html/psaw.
Mike Colias, a Chicago-based freelance writer, can be reached at [email protected]