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For other articles and previous issues click here. April 12, 2004 Bringing
the Patient Into Patient Safety Involving patients and families to a greater degree in the healthcare experience can only benefit patient safety. When patients ask questions about medications or a test that has been ordered, they remind the practitioner to recheck that the correct procedure will be done. Since most medical errors are system-related—rather than attributable to individual negligence or misconduct—more effective safeguards can prevent mistakes from reaching the patient. Patients can serve as a safeguard against untoward events by paying attention to the provided care. They can let practitioners know if a possible error is being made. Patients can also help by ensuring that all clinicians have pertinent health information to provide safe care. Unfortunately, the information a patient shares with one provider is not always passed on to the next provider. Patients can help prevent mistakes by keeping practitioners informed of their needs and specific health issues. While patients can play an important role in preventing adverse events, involving them in the process can be challenging. Patients may not understand the value of their roles in the prevention of errors or be reluctant to participate. They may be hesitant to speak up or disinclined to help practitioners. Overcoming Barriers Language. Many patients speak little or no English. This fact can make using written materials to educate patients about their care or their role in maintaining safety less effective. Verbally translating information from English to another language may compromise the content of the patient educational materials. Literacy. Many people who can sign their name may lack the skills needed to access and assimilate information. Some are unable to read above a fifth-grade level and cannot comprehend materials written at a more advanced level. Some health education materials are written above an eighth-grade level, making it difficult for patients to use the information intended to help them. Written information about the patient’s role in safety may be ineffective for communicating with low-literacy patients. Also, people with low literacy typically do not confide in practitioners their difficulties in reading or understanding materials because they often feel embarrassed and do not want to be judged. Cultural differences. In many places, patients come from a wide range of ethnic groups. Religious, social, and cultural beliefs about health vary considerably among these groups. Many ethnic groups expect a more formalized relationship with healthcare professionals. In such groups, asking questions or speaking directly with patients can be considered bad manners. Simply telling a patient to feel comfortable in expressing his or her concerns will not necessarily yield a response. The practitioner must establish good relationships with patients for them to speak freely about problems or issues. Trust takes time to establish, which can be a problem in the episodic workflow of an imaging department or facility. In most cultures, patients accept the physician’s decision or the allied health professional’s direction without question and are unaccustomed to making decisions about healthcare services, much less pointing out a provider’s mistake. The stress of serious illnesses can compound communication difficulties. Emotional. Emotional issues can hinder the patient’s ability to partner with practitioners. For example, the patient’s illness may have significantly affected his or her usual demeanor or heightened worry about the family or job. They may be preoccupied with financial concerns or personal challenges to effectively participate in their care. Silence does not necessarily mean lack of interest in participating. Patients might simply need more time to address what they view as more pressing issues before fully participating in their care. Patients may avoid asking questions for fear of offending the healthcare provider. They may have attempted to express concerns in the past and were rebuked or belittled. Caregivers frequently tell patients not to worry and to leave their care up to the providers. People may fear that bringing up concerns may cause an error. Patients may not realize that their concerns are legitimate. They may feel awkward or pushy or think they won’t be heard or that comments won’t do any good. Patients may believe that errors would never happen to them. Often, patients believe that hospitals and the people who work in them could never make a mistake. Indifference may also be a barrier. Some patients resent being asked to participate in their care, even if it helps create a safer healthcare environment. They feel that their only role is to receive care and not to help providers. Communication Cure Overcoming language problems. If a patient does not speak English well, a bilingual staff member or an interpreter can be used so the patient can provide information about his or her history and current condition and ask questions about treatment. It can be helpful to use someone other than a patient’s family member or friend as an interpreter because the patient may feel uncomfortable sharing personal information or expressing concerns. Instruct interpreters not to omit information related to sensitive issues about the quality of care or other concerns raised by the patient. An objective interpreter can help reduce the patient’s reluctance to share personal medical history, current symptoms, and concerns while maintaining his or her right to confidentiality. Education and safety materials should be translated into the patient’s language. This may seem an obvious suggestion, but it is important to remember that many recent immigrants may not read English, and even if they do, they are often more comfortable reading in their own language. Bilingual materials should be made available to patients whenever feasible. Handling literacy issues. Patients who have low literacy levels often feel ashamed and go to great lengths to conceal their reading or comprehension difficulties, making the literacy barrier difficult to detect. People who work with patients must carefully screen for such problems. Elicit patient feedback and evaluate his or her understanding by asking questions and reiterating key points. If the patient experiences difficulties in grasping or retaining information, simplify the information and verify the patient’s comprehension in a respectful manner. Written materials about patient safety and the patient’s role in reducing errors may need to be supplemented or replaced by discussions and visual aids that illustrate key points. Seeking patient questions and feedback will help assess comprehension and engage them as willing participants in their care. Observing cultural differences. To promote patient safety and reduce errors, healthcare providers must learn more about the cultural beliefs and practices of ethnic populations. Knowing what to say is as important as knowing how to say it. Caregivers need a general understanding of how different cultures are likely to define health, view illness, and respond to death. The role of family, whether or not medications and pain treatments are acceptable, and the manner in which their religion or philosophy supports them in times of stress are also valuable factors to be understood. Hospital administrators should be aware of any specific immigration trends in the area the facility serves. A blossoming Hispanic, Asian, or other immigrant community can provide operational challenges and a chance to capture a new patient market. Family Orientation Many healthcare organizations have developed resources for staff members to use when providing care to patients from different cultures. These guides remind caregivers of the patient’s cultural perspectives and values and describe how nonverbal behavior should be interpreted. While all members of one cultural group do not behave in exactly the same manner, a basic understanding of the culture promotes safe care and effective communication. Emotional. Patients gain a sense of control when clinicians take time to discuss the plan for their care, help them choose options, and educate them about their illness. Of course, for an RT, it’s only appropriate to discuss the imaging test’s technique; defer questions about the condition, results, or treatment plan. Providing individualized attention to patients can have a dramatic effect on their willingness to disclose concerns about care. When patients and their families trust healthcare professionals, they are better able to communicate effectively, cooperate in treatment, and cope with uncertainties. The trust of patients and family members depends on the degree to which they see caregivers as competent, caring, and responsible. Being proactive in providing information and anticipating questions is the first step in involving patients in error-reduction activities. Practitioners and allied staff can actively seek patient participation by making a habit of asking them if they have questions, if there is anything that has been overlooked, and if there is anything else that must be done for them. Healthcare professionals can work in partnership with patients in a number of ways. Patients should be told what will be done before it happens. Caregivers must take the time necessary to find out what questions patients may have before proceeding. And, most important, this conversation should be done without using medical terms and acronyms unfamiliar to the patient. By seeking and receiving explanations about procedures that will be performed, medications that will be administered, or other activities to be conducted from the appropriate person, patients are given an opportunity to serve as “checks” in the system. The patient’s request for clarification could easily help prevent a mistake. Activities in a healthcare organization are often confusing to patients. It’s reasonable that the patient or family may have perceived a situation inaccurately and expressed a concern about safety. How caregivers handle a situation in which the patient speaks up will influence the patient’s willingness to voice other concerns. That’s the reason why it is vital to deal with situations in the appropriate manner. If a mistake has not been made, explain the reason it may have looked that way to the patient or family member. Don’t cause patients or family members to lose face—they may feel foolish and embarrassed once they learn that their perceptions were incorrect. Acknowledge the validity of their concern and apologize for the confusion or lack of communication that may have created the concern. Thank them for paying attention to their care and feeling comfortable enough to ask the question. Encourage them to feel comfortable in speaking up about any concerns or questions about care. Appropriate Response A growing number of news reports and federal and local initiatives call for more consumer involvement in the prevention of medical errors. However, we cannot expect patients and families to assume greater responsibility for the safety of healthcare services by merely telling them how to become more involved. Several factors inhibit the ability of consumers to serve as effective “safety watchdogs” during the delivery of healthcare services. Healthcare providers must understand the common barriers that influence the patient’s ability to serve as a “checkpoint” in the system and work to overcome these barriers. The response of healthcare professionals to patients’ questions, concerns, and feedback also directly influences the degree to which patients will be involved in helping to prevent or intercept errors. The thought that practitioners would perform in any way less than perfect does not mesh with our professional concept of infallibility. Yet, medical errors do occur. Our perception of what causes errors can actually prevent us from obtaining help from patients. We may believe that errors occur because the practitioner was not careful enough or he or she didn’t try hard enough. If a patient asks that the nurse confirm the accuracy of the medications being administered or that the surgeon recheck the operative site, the subtle inference is that that patient is challenging our professionalism. Such challenges can be uncomfortable; thus, healthcare professionals may be reluctant to encourage patients to speak up. Healthcare professionals must admit that human errors will occur despite everyone’s best efforts. Overconfidence in the abilities of caregivers can cause harm. Most errors are the result of a poorly designed system or process. Securing the patient’s participation as one of the safeguards in healthcare delivery helps to build a system that is more resistant to errors. Involving patients and their family members in medical error reduction and safety improvement requires more than simple education. Recent data show that patients want to be more involved in their care and they have a vested interest in the outcomes of care. Healthcare professionals must create opportunities for involvement and show people how to take advantage of these opportunities. Successful public participation in patient safety improvements will require changes in attitudes and behaviors by both patients and caregivers. — Patrice L. Spath, BA, RHIT, is a healthcare quality specialist, author of From Quality to Excellence: Using Comparative Data to Improve Health Care Performance, and a partner in Brown-Spath & Associates. |
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