Why they have to: Patients and patient safety

Last week, Bob Wachter, a patient safety leader I admire, wrote a post Can Patients Help Ensure Their Own Safety? More Importantly, Why Should They Have To? As the title suggests, Wachter addresses both the utility of patient participation in safe practices and the necessity for this.

On occasion, these issues make my own hard drive blink. They did most recently when I considered how patient involvement squared with principles used to engineer highly reliable systems while writing From Safe Practices to Safe Patients: The Evolution of a Revolution (published on the Medscape platform last month.) At one point, I considered jettisoning the piece, convinced that allowing variability of the magnitude that patients (humans) necessarily introduce to a system couldn't be defended, let alone operationalized.

Wachter seems close to casting patients overboard, too. He rightly points out that the ability to self-advocate varies both between individuals (who possess differing knowledge, abilities, desire, and social support systems) and within one individual across time (subject to things like severity of illness, level of consciousness, and use of medications). Systems engineers (one is quoted in his post) tell us that variability is the enemy of stability. And finding variability in a system and driving it down is what gets these folks out of bed in the morning.

I've wanted to do this kind of "people parsing" on occasion myself.


Who wouldn't like to eliminate the outliers in the patient population we serve? Hypervigilant, distrustful patients can be problematic. At the other end of the self-advocacy continuum are unconscious Jane Does. They, too, interrupt work flows. But eliminating variability in measures that inform patient safety risks treating all patients like the least common denominator: the "bar" gets set at the level of the anesthetized patient.

And here's the other problem: Neutralizing patient input in patient safety assumes that the system is sound. That is, it produces reliable results if you just sit back and let the system do its thing.

Wachter does something I like to do: comparing the experience of being a passenger on a commercial aircraft to being a patient. I travel a lot, enjoy flying, and I'm perfectly happy assuming the safety duties expected of every other passenger on board. I wouldn't think of offering to lend a helping hand to those on the flight deck.

A commerical aircraft crashes 1 time in every 6 million departures. The fitness of systems used in commercial aviation clearly do not depend upon input from me. I'm okay with saying that if I get booked on the unlucky 1 in 6 million flight, "It's my time." But safety leaders in aviation are not. They continually strive to improve the system, to find ways to drive the incidence of error down, further diminishing the likelihood of 1 in millions events.

A preoccupation with making things safer is what distinguishes aviation (and other high consequence industries with reliable safety records) from healthcare. There's no doubt that the "alert" signals engineered into aircraft are easier to read than those built into humans. But that does not diminish the effectiveness of an alert.

I've been a nurse for a long time, and I suspect I share many of Dr. Wachter's feelings about what professionals should do for their patients. We have duty and desire, but, at this point in time, we do not have the means. Wachter is right to call for systems that turn intention into outcome.

But the answer to, "Why should they have to?" is that safest care won't happen without them.

Participatory Healthcare at Grand Rounds

Grand Rounds is a "must visit" place today irrespective of whether you're a consumer, healthcare provider, or have another dog in the fight to improve healthcare. You'll find clear explanations of what "participatory healthcare" is and have a chance to assess how it's emerging.

One thing about participatory healthcare that jumps out at me is how well it aligns with the way I was taught to approach patient care when I was an undergrad nursing student in the mid '80's. That curriculum also came with a hefty dose of "change management" theory, something that drew disdain from the "where's the beef?" crowd and, unfortunately, didn't change much.

But what does seem to be changing things is the information revolution. Patient access to information, ideas, outcomes, and communication modalities is doing more than just shoring up foundational changes in "how we do things around here," (the easiest way to describe healthcare culture). These changes must occur to make the delivery of healthcare more reliable, more safe.

I see patient engagement as transformational, meaning we're likely to get somewhere better as a result of letting patients take the lead for part of the journey. So take a trip to Survive the Journey and see how far we've come.

When you do, you'll find that a number of the people who contributed to the participatory healthcare Grand Rounds appear on the inaugural list of "Top 25 Patient Safety Tweeps" I published last month, among them Dave DeBronkart (epatientDave), Amy Romano (midwifeamy), and John Sharp (JohnSharp). The experience of patients is central to efforts to improve patient safety. So are initiatives and incentives arising from clinicians, organizations, payors, industry partners, regulators, and academics. I'll publish an updated list this Friday, 10/16/09.

I welcome nominations of individuals or organizations from any of these categories for consideration on Safety Nurse's Top 25 Tweeps for Patient Safety list. The entity must have a current, active presence on Twitter. The volume of tweets is less important than the quality of patient safety information that's passed along.

Thanks for participating!

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.