How Your Patients Can Help You Stop Medical Errors
revealed two important points: 1) Patients are routinely dismissed or not heard when trying to alert care team members that something is not right, and... 2) Patients know when you are not using safety protocols.
Medical error is not a minor problem. Extrapolating the results of this study, conducted in Massachusetts, across the entire country suggests that 1 in 5 of all adults have recent experience with a medical error in their own care of that of a family member. To make a dent in the amount of harm, you must use your patients and their families as critical members of your safety team.
4 Ways to Get Your Patients to Help Prevent the Preventable
1. Accept that patients and their families are astute observers of what is happening and why things are going wrong. According to the study, patients that have been harmed are very aware of the absence of precautions or other fail-safes for preventing harm, including issues related to equipment maintenance, oversight of clinician and staff hand hygiene practices, and systems for preventing patient misidentification. You are only fooling yourself to think they don't notice. Use that as motivation to do what you know you should be doing, and probably would do if a supervisor or peer was watching. Your patients are watching.
2. Listen to, and assess the inputs from patients when they tell you something is not right. Make no mistake, patients and families know when they are being dismissed. Patients that have been harmed can point to the exact moment they tried to express concerns about their care and were ignored. Many patients described their physician or other health care professional as either disinterested or inattentive.
3. Explain why you are repetitively using safety protocols such as patient identification. In hundreds of site assessments, while observing patient identification protocols when a patient first presents to the unit, I have never heard a caregiver explain why the identification protocol was being used nor how often it would be used. That is the time (and it only takes a few seconds) to set the expectation with the patient and family about how and why the patient identification protocol will be conducted, and most importantly what they should do if it is not used.
4. Demonstrate for the patient how to express a safety concern. Patients, just like clinicians, must know how to make an assertive, stop the line statement using the common, accepted terminology in your clinical setting. It only requires a few seconds to say something like, "If we fail to check your armband, you should stop us by saying, 'Nurse, I'm concerned. No one verified my identity. Let's do that now before we proceed.'"
None of these four action steps is possible if you don't change your culture
Organizations that don't value patients inputs about the care they are receiving are that way because listening to patient concerns is "not the way we do things around here." That is a cultural problem. Sustainable cultural change can only be driven by leaders and boards that prioritize safety and quality and adopt management and leadership practices designed to purposefully and intentionally change the culture. An effective patient safety culture prioritizes identification of errors and near-misses - even from patients and their families. Here's a quick test you can run: Go ask several of your front-line leaders this question, "What one action have you taken today to create the belief that we value, and listen to, the safety inputs of our patients?" If you are not satisfied with the answer you receive, remember that changing culture is completely and totally the responsibility of the leadership team.
Want to get create the patient safety culture that values and takes advantage of patient inputs? If you need help creating this type of culture, LifeWings can help. Schedule a call today.