Participatory Safety

Patient safety is a natural fit with participatory medicine. And not because initiatives that include the word "patient" should seek to involve patients in some nominal, "so glad you could make it" fashion. I don't picture patients manning the Guest Book at the reception when I consider the potential of patients to improve the safety of care.

Patient safety is a scientific discipline, one that seeks to make complex systems work reliably. Systems turn intention into outcome whether you're flying a plane or reconstructing a breast.

Transparency, disclosure, error reporting, and an urge to prevent errors by learning from the mistakes of others are hallmarks of patient safety. People who champion the science of patient safety borrow from cognitive psychology, systems engineering, and human factors, recognizing the inherent fallibility of humans and looking for ways to mitigate the consequences of human error. These are principles patients should know.

Healthcare has suffered from the erroneous perception that good people automatically produce good outcomes. Both patients and providers have had a role in shaping this belief. Since we're all seated at the grown-ups' table, let's get this on it: Healthcare providers are fallible humans. It's not "if" we make mistakes, it's when. What really matters is the consequences of these mistakes, that is, whether they make it to you.

In highly reliable systems, the intended outcome is delivered under both normal circumstances and when conditions destabilize or become hostile. Intended outcomes arise from work processes that build in barriers, redundancies, and lots of opportunities to discover and mitigate errors set in motion before they cause harm. Highly reliable results do not come because the captain of an aircraft is godlike or the engineer at the nuclear power plant was the smartest kid in his class. High reliability comes when competent people:

• perform within a system designed to accomplish the task at hand,
• believe that the system could fail, and
• are empowered to act when a threat, or potential threat, to safety is perceived

It's fair to say that the 100,000 or so unintended deaths due to medical errors and healthcare acquired infections that occur in the US each year disqualifies our industry from being a highly reliable one. So what does participatory healthcare mean for patient safety?

Tons, but here's one of the most obvious: When a patient is seen as a participant in, rather than the object of, care, the system becomes more stable. At its most basic, patient participation adds a valuable redundancy at high stakes junctures of care (as occurs when a patient confirms identity before blood is drawn, verifies the affected area before a biopsy is underway, or asks a provider, "Have you washed your hands?"). Moving into less concrete domains, patients are uniquely positioned to uncover a wide array of errors that have been set in motion.

Here's an example, one that illustrates how patient engagement prevented a serious warfarin overdose:


I know a lot about this case because it happened to me. I derailed a 17.5 mg overdose of warfarin which had passed through a series of high-end automated barriers, including electronic MARs and bedside bar-code medication administration. (You can read the complete story here.)

The take-away lesson is that the warfarin overdose wasn't averted by any special "insider knowledge" of warfarin or the medication use process that I possessed. My participation came in the form of a question ("Do you usually give someone who is close to having a therapeutic INR a big dose of warfarin?"). The nurse's willingness to believe that a concern raised by a patient merited investigation is what allowed the error to surface.

From an engineering standpoint, "patient engagement" takes on value beyond its ability to help people understand a plan of care, decide if it's for them, and manage barriers. Engaged patients add a valuable layer of error detection, one that often does not exist if the patient cannot or will not participate in care (which, by the way, is why advocates and surrogates are such important players in patient safety.)

To make participatory processes work for patient safety, look for opportunities to engage in safety initiatives at the system level. I maintain Florence dot com as a real-time patient safety primer, a place where both patients and providers learn about the science that informs safest practices. Daily tweets that run here point to information and resources that represent best practices, case reports, exemplars, and stumbling blocks. I hope you'll find helpful information here and let me know when you have a safety-sensitive story to share.

Because before you get to the bedside, you want to be sure you're at the table.