Where Does Patient Safety Begin?

The National Patient Safety Foundation defines patient safety as the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of health care.¹

The Office of Inspector General has issued 17 reports in the past 10 years regarding patient safety. Specifically, in its Report in Brief, May 2022, the OIG states² that 25% of Medicare patients experience patient harm during their hospital stay. Patient harm includes adverse events and temporary harm events:

• 12% of patients experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death.
• 13% of patients experienced temporary harm events, which required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures.

Not Just a Hospital Issue

Now, before you go thinking that patient safety is only a hospital issue, think again. The National Academies of Sciences, Engineering, and Medicine³ have identified the types of clinical errors to include diagnostic errors. They define a diagnostic error as “the failure to establish an accurate and timely explanation of the patient’s health problem(s) or communicate that explanation to the patient.” It is known that 57% of all diagnostic failures occur in ambulatory care settings.⁴

With this in mind, are you gathering the right information you need to make a clinical diagnosis? Are you relaying this accurately and in an understandable manner to the patient? Are you performing re-evaluations at appropriate times during the patient’s treatment plan to reassess their progress and response to care? Is your diagnosis of the patient accurate and is your treatment effective within a reasonable time frame?

How can you be assured you are collecting the right information? You can start by doing the following:

Review Your Intake Forms

• Do you ask pertinent questions regarding not only the patient’s chief complaints, but also their past medical, social and family history?
• Do you know if the patient has had any recent surgeries?
• Is the patient on any medication – or had a change in medication or new allergy identified recently?

Assess the Quality of Your History-Taking

• Do you interrupt your patient when they are talking? If you do, research shows this results in a diagnostic error in about one out of every 20 patients you see.⁵
• Do you specifically ask the patient about any past and recent medical history, and their family and social history? They may not think it is pertinent and may not document it on the intake form.
• Has the patient completed a Review of Systems and have you taken this into consideration with your history-taking?

What Should We Do Better?

• Let our patients tell their stories – uninterrupted.
• Ask the right questions – and let our patients respond as you listen for meaning. (This is known as reflective listening.)
• Ask deeper, probing questions and reflect on the information our patients share while we are listening to them speak.
• Always look into their eyes when they are speaking.
• Tell the patient’s story back to them to achieve clarity about the patient’s problems and concerns.
• Avoid making snap judgments or premature diagnostic assumptions based on our own biases. (We all have them, by the way.)

Begin today by testing yourself in these areas. Give your staff and other doctors permission to be frank and objective, and then develop a plan moving forward to improve. Let’s avoid preventable errors and risks to our patients.

Editor's Note: This is the first in a series of articles by the author on patient safety and avoiding clinical errors.

References

1. Cooper J, Gaba D, Liang B, et al. The National Patient Safety Foundation Agenda for Research and Development in Patient Safety. Medscape Gen Med, 2000;2(3):E38.
2. Office of Inspector General. Report in Brief, May 2022.
3. Improving Diagnosis in Health Care. National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press, 2015.
4. AHRQ Publication No. 21-0047-8-EF, August 2021.
5. Improving Diagnosis, Op Cit.