From the January 26, 2006 issue
Most patient safety advocates would agree that educated patients are the safest patients. The concept is clear: patients who know what to expect will be more aware of potential risks and errors. On the other hand, exactly how organizations educate patients about their role in safety and encourage their contributions is far less obvious.
At a minimum, most healthcare providers attempt to involve patients in safety by distributing an advisory (e.g., brochure, pamphlet, handout, content in patient admission materials) that covers general safety tips and encourages patients to speak up about hazards. The emphasis is usually on actions patients can take directly to help ensure their safety. Unfortunately, the impact of safety advisories has not been well studied. While they certainly may help to reduce errors, a recent analysis of five leading national safety advisories suggests that they may also result in unintended consequences that can compromise patient safety efforts (Entwistle VA, Mello MM, Brennan TA. Advising patients about patient safety: current initiatives risk shifting responsibility. Joint Commission Journal on Quality and Patient Safety September 2005;31(9):483-94). The study was conducted with participants from academic, clinical, administrative, and consumer backgrounds who had been promoting or researching patients' perspectives on and contributions to safety. Based on this analysis, we put together questions to help you assess and improve the patient safety advisories that you distribute to patients.
---Are the safety tips well defined?
Patients who are ill may be less likely to act on vague safety tips, such as "Ask questions," and more likely to heed advice if the instructions are clear and concise, such as "Make sure your name is spelled correctly on the name bracelet applied to your wrist when you are admitted."
---Is the basis for the safety tips provided?
Entwistle et al. note that recommendations without a rationale for use represent missed opportunities to broadly educate the public about safety issues in healthcare. Knowing the basis for a safety tip also helps patients remember it and use it.
---Are the safety tips prioritized?
Participants in the study noted that the sheer number of tips in an advisory may make people feel overburdened or guilty because they cannot act on all of them. Telling patients which safety tips are most important based on likely impact on their safety could help improve compliance with the most important ones.
---Does the advisory specify what the organization is doing to enhance safety?
A list of safety tips alone may imply that patients are the only ones looking out for their safety. Describing what the healthcare organization is also doing to ensure safety offers patients some measure of reassurance.
---Is the difference between harm from errors and unpreventable harm covered?
If patients do not understand that some adverse outcomes in healthcare are not preventable, they may erroneously equate all bad outcomes with negligence.
---Are patients advised how to report hazards and errors?
Patients and families may perceive risks during the provision of care that healthcare providers may not notice. Patients need a means of reporting these risks as well as perceived errors so they can make you aware of them.
---Is the advisory written from the patient's perspective?
According to the authors, safety advisories are often written from the provider's perspective. There's little or no attempt to learn about patients' beliefs, concerns, and self-perceived information needs, or to test the advisory before dissemination.
---Do the safety tips require patients to check or challenge healthcare providers?
Advice that requires checking and challenging providers is particularly problematic for patients. Patients may fear being labeled as difficult if they speak up. Staff also may be less inclined to interact with patients who challenge them, potentially worsening safety risks.
---Does the advisory shift responsibility for safe care from the provider to the patient?
Entwistle et al. found that patients may perceive safety advisories as inappropriately shifting responsibility for safe care from the healthcare provider to the patient, particularly if there's little evidence that the healthcare provider is also taking steps to improve safety. The authors also conclude that the perceived shift in responsibility might increase the patient's and family's feeling that they could have done more in the event of harm from an error.
---Is it implied that patients need to "work around" system deficiencies?
The tone of the advisory could imply that patients must work around system deficiencies to be safe, perhaps without much help from professional staff. Even if the advisory instructs people to "work with your healthcare provider," Entwistle et al. found that patients may be uncertain about the extent of support they will receive from staff. Thus, the tone of the advisory should be collaborative and staff must consistently support, and reinforce the messages about safety.
---Do staff reinforce the safety tips in the advisory and offer patients practical support in carrying them out?
Healthcare providers may not regularly discuss the safety tips in the advisory with patients and give them personal encouragement to follow them. In fact, study participants stressed that patient involvement in care may not be a top priority for hospitals in their quest for safety. Said one of the participants: "Systems aren't set up to have you involved...you have to bully your way in to be a partner...and you're really not a partner, you're an imposition at that point. And patients feel that." Beyond distributing advice, system changes are needed to ensure that patients' contributions to error prevention are encouraged and met with appropriate responses.