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What’s New in the Patient Safety World

October 2019

Helen Haskell:

Putting the Patient in Patient Safety



Many of you have read Helen Haskell’s recent essay in the BMJ “Unleash the power of patients to make care safer around the world” (Haskell 2019). It is a compelling argument that we need to bring patients and their families into more of our patient safety activities.


We’ve long recommended incorporation of patients or their families in several of your patient safety initiatives. These include reporting of safety events, and participating in Patient Safety Walk Rounds, FMEA’s, and RCA’s.


In our February 2012 What’s New in the Patient Safety World column “OIG: Hospitals Fail to Recognize Most Cases of Harm” we discussed an article in the Canadian Medical Association Journal (Daniels 2012) which looked at the impact of surveying families of children admitted to a Children’s hospital to see if they saw events they considered to be adverse events. A total of 321 events were identified in 201 of the 544 family reports received. Of these 48% were determined to represent legitimate patient safety concerns. Types of events most often included medication problems, miscommunications (between staff or between staff and families), and equipment problems. Only 8 of the adverse events reported were also reported by health care providers. There was also little change in reporting by health care providers after implementation of the family reporting system.


The Daniels article demonstrates that the perspectives of families and health care workers may differ regarding adverse events or near misses. Importantly, it shows that some of the barriers that prevent health care workers from reporting adverse events or near misses may not apply to families. Such family reporting systems therefore provide an opportunity (another set of eyes and ears) to identify potential patient safety issues in need of improvement.


Incidentally, in the Daniels study families noted that apologies were given only in a minority of cases but, when they were given, they were usually considered adequate. See our prior columns on disclosure and apology (June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” and our November 2010 What’s New in the Patient Safety World column “IHI: Respectful Management of Serious Clinical Adverse Events”).


Families responding to the surveys also readily volunteered to participate in future safety improvement initiatives by the hospital.


So, in addition to removing barriers to adverse event reporting for staff, consider using other tools (such as the family adverse event reporting tool discussed above) to better identify patient safety concerns in your facilities. Such a tool may not only help you identify more opportunities to improve but likely also has a positive impact on patient and family satisfaction.


We’ve found that patients and families tend to be even more reluctant than staff to report errors, mistakes, or conditions that may contribute to adverse outcomes. That is why it is extremely important to provide them with a way of reporting in a confidential manner. Note we don’t say “anonymous” since we need in most cases to actuall speak to the patient or family. What you want to convey is that they can speak with someone (eg. a patient advocate or your patient safety coordinator) without fear that their care will be compromised.


Having a patient or patient’s family participate in a FMEA (Failure Mode and Effects Analysis) can be very valuable. When we’ve worked with hospitals on FMEA’s for either breastmilk mixups or switched babies, the perspectives of patients/families have been very important. They often tell you about events or conditions your own staff would not have noticed or been aware of.


In our columns on Patient Safety Walk Rounds (see our Patient Safety Tips of the Week for October 7, 2014 “Our Take on Patient Safety Walk Rounds” and February 27, 2018 “Update on Patient Safety Walk Rounds”) we discussed inclusion of a patient or patient family member. We noted that a Board member might fulfill that role, but Board members may have an “insider” bias. Having an “outsider” pair of eyes and ears may be important. You may be surprised at the things they point out which you had not perceived yourself.


In our July 12, 2016 Patient Safety Tip of the Week “Forget Brexit – Brits Bash the RCA!” we noted we all have problems figuring out how to fit patients and families into the RCA process. Our many columns on critical incident response and disclosure and apology (see list of prior columns below) have emphasized how after disclosure and apology we need to keep patients and families in the loop as we complete our RCA’s and implement actions to prevent similar events in the future. But few of us have figured out how to include patients or their families in the actual RCA process. Often patients and families have unique perspectives and observations that healthcare workers have not seen (or have been unwilling to admit!). More and more research is demonstrating that patients and families impacted by adverse events are highly motivated to help ensure similar events don’t occur to other patients. While we don’t have the perfect solution to inclusion of patients and families on the RCA team, we do recommend that as part of the disclosure and apology process we also appeal to them “we need your help in determining exactly what happened and how we can prevent similar events”. We’ve also stressed the need to avoid intimidation when such interactions with patients and families occur (see our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It”). Don’t hold such meetings in a formal Board Room or have 1-2 family members sitting across a table full of individuals dressed in suits or white coats. You must keep the meeting as cordial as possible, expressing your sincere apology and sincere desire to get their perspectives on the events and give them plenty of time to ask questions and present their observations and concerns.


See our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines” for many other recommendations to include in your RCA process.


Patient/family engagement in patient safety activities needs to be an important goal for all organizations. Undoubtedly, local cultures may be facilitators or barriers to such engagement. We think you will be surprised at the positive perspectives patients and their families bring to your organizations.



Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:

July 24, 2007              “Serious Incident Response Checklist

March 30, 2010           “Publicly Released RCA’s: Everyone Learns from Them

April 2010                   “RCA: Epidural Solution Infused Intravenously

March 27, 2012           “Action Plan Strength in RCA’s

March 2014                 “FMEA to Avoid Breastmilk Mixups

July 14, 2015              “NPSF’s RCA2 Guidelines

July 12, 2016              “Forget Brexit – Brits Bash the RCA!

May 23, 2017              “Trolling the RCA



Some of our previous columns on Patient Safety Walk Rounds:


October 7, 2014 “Our Take on Patient Safety Walk Rounds

February 27, 2018 “Update on Patient Safety Walk Rounds



Some of our prior columns on Disclosure & Apology:

July 24, 2007              “Serious Incident Response Checklist

June 16, 2009              “Disclosing Errors That Affect Multiple Patients

June 22, 2010              “Disclosure and Apology: How to Do It

September 2010          “Followup to Our Disclosure and Apology Tip of the Week

November 2010          “IHI: Respectful Management of Serious Clinical Adverse Events

April 2012                   “Error Disclosure by Surgeons

June 2012                    “Oregon Adverse Event Disclosure Guide

December 17, 2013     “The Second Victim

July 14, 2015              “NPSF’s RCA2 Guidelines

June 2016                    “Disclosure and Apology: The CANDOR Toolkit

August 9, 2016           “More on the Second Victim

January 3, 2017           “What’s Happening to “I’m Sorry”?

October 2017              “More Support for Disclosure and Apology

April 2018                   “More Support for Communication and Resolution Programs

August 13, 2019         “Betsy Lehman Center Report on Medical Error

September 2019          “Leapfrog’s Never Events Policy



Other very valuable resources on disclosure and apology:








Haskell H. Unleash the power of patients to make care safer around the world: an essay by Helen Haskell. BMJ 2019; 366: l5565



Daniels JP, Hunc K, Cochrane DD, et al. Identification by families of pediatric adverse events and near misses overlooked by health care providers. CMAJ 2012; 184: 29-34





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