Patient Engagement and Safety

Patient Engagement and Safety | PSNet 30/01/22, 20:02
Patient Engagement and Safety

September 7, 2019
Background
The traditional paternalistic model of medicine, in which
patients have little voice in their care, has slowly but surely
been evolving toward a model in which patients and clinicians
work in a partnership toward the common goal of improved
health. As articulated in the seminal Institute of Medicine
report Crossing the Quality Chasm, such patient-centered
care should be "respectful of and responsive to individual
patient preferences, needs, and values and ensure that
patient values guide all clinical decisions."
While many patient safety interventions have used traditional

models of e!ecting change, such as changing provider
behavior, encouraging interprofessional collaboration, and
enhancing the culture of safety, the patient's role in safety
has not been overlooked. The Joint Commission mandated
that health care organizations "encourage patients' active
involvement in their own care as a patient safety strategy" as
a National Patient Safety Goal in 2007, catalyzing research into
how patients may partner with providers to prevent errors–
and how patients may themselves inadvertently precipitate
errors.
Patients' Role in Preventing Errors

E!orts to engage patients in safety e!orts have focused on
three areas: enlisting patients in detecting adverse events,
empowering patients to ensure safe care, and emphasizing
patient involvement as a means of improving the culture of
safety.
Hospitalized patients are routinely surveyed about their

satisfaction with the care they received, and recent research
has examined whether patient surveys may be used as an
error detection mechanism. Studies in the inpatient setting
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have found that patients often report errors that were not
detected through traditional mechanisms such as chart
review; indeed, patient-reported errors formed the basis of
landmark studies of adverse events after hospital discharge.
Concerns have been raised, however, that patient complaints
may center on poor service quality rather than on clinical
adverse events.
Source: Adams RJ, Tucker G, Price K, et al. Self-reported

adverse events in health care that cause harm: a population-
based survey. Med J Aust. 2009;190:484-488. [go to
PubMed !]
Patients are also being encouraged to take an active role in

their own safety. The Agency for Healthcare Research and
Quality's Questions Are the Answer program and 20 Tips to
Help Prevent Medical Errors fact sheet, as well as The Joint
Commission's Speak Up initiative, are examples of programs
that educate patients about safety hazards and provide
specific questions that patients (and their caregivers) can ask
regarding safety. Although patients have voiced concerns
about engaging in behaviors that may seem confrontational
(for example, asking their clinician if she washed her hands),
some preliminary studies have found that active engagement
of patients can improve adherence to safety practices. The
widespread availability of electronic medical records is also
being used as an opportunity to engage patients in safety
e!orts. Early studies have leveraged information technology
to incorporate patients in medication reconciliation and early

identification of outpatient adverse drug events.
Finally, hospitals are increasingly recognizing the crucial role

of patients' perspectives in establishing a culture of safety.
Many institutions (such as the Dana-Farber Cancer Institute)
have prioritized engaging patient representatives in the design
and nurturing of safety e!orts, and emphasize transparency in
reporting errors and care problems. The active engagement of
patients in safety e!orts has extended to allowing patients
and families to summon rapid response teams, rather than
waiting for clinicians to respond.
Studies in the intensive care unit and inpatient pediatric
wards have shown that interventions that explicitly include
patient and family engagement can improve safety culture and
may reduce adverse event rates.
Although patient engagement is a promising strategy for error

reduction, there is reason for caution on several grounds.
From a systems engineering viewpoint, the level of patient and
family participation will always be di"cult to predict, leading
some to argue that a robust safety program should not
depend on such engagement. Furthermore, patients and
caregivers already shoulder a significant emotional burden for
ensuring safety while hospitalized. An important study found
that a surprising number of patients and family members feel
guilty after a medical error, and another study found that
most parents of hospitalized children felt personally
responsible for ensuring their child's safety in the hospital.
Engaging patients in error prevention therefore risks simply
shifting the responsibility for safety from providers and
institutions to patients themselves.
Patients' Role in Precipitating Errors

Patients themselves may be a cause of errors as well as a
solution, and some early studies have sought to analyze and
classify patient errors. These errors arise from the same
underlying causes that contribute to clinicians' errors–while
patients may engage in intentionally unsafe behavior, more

commonly, patient errors are attributable to the di"culties
inherent in an individual's interaction with a complex system.
One study classified patient errors into action errors, which
are errors of patient behavior such as failure to attend a
scheduled appointment, and mental errors, which include
thought process errors such as failing to take a medication as
prescribed. Both of these types of error are influenced by
other definable safety hazards; for example, low health
literacy and poor provider–patient communication are clearly
linked to medication errors. Therefore, a useful construct may
be to view patient error as an undesirable outcome that
clinicians should actively seek to prevent, using tools that
target known risk factors for such errors. For example, lack of
knowledge or fear of asking questions may cause patients to
take medications incorrectly, but interventions such as
pictogram-based medication labels can decrease dosing
errors and improve medication adherence.
Current Context
Patient engagement in safety e!orts is a strong priority of
influential regulatory and governmental organizations. The
Agency for Healthcare Research and Quality and the World
Health Organization sponsor a variety of programs centered
around patient education and encouraging patient
perspectives to improve safety culture. In addition to its
prioritization of patient engagement through the National
Patient Safety Goal, The Joint Commission also provides
educational resources for patients around safety measures in
pediatric, hospital, and surgical settings.
This project was funded under contract number

75Q80119C00004 from the Agency for Healthcare Research
and Quality (AHRQ), U.S. Department of Health and Human
Services. The authors are solely responsible for this report’s
contents, findings, and conclusions, which do not
necessarily represent the views of AHRQ. Readers should
not interpret any statement in this report as an o!cial
position of AHRQ or of the U.S. Department of Health and
Human Services. None of the authors has any a!liation or
financial involvement that conflicts with the material
presented in this report. View AHRQ Disclaimers

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Patient Engagement and Safety | PSNet 30/01/22, 20:02

While many patient safety interventions have used traditional

Patients' Role in Preventing Errors

Hospitalized patients are routinely surveyed about their

Source: Adams RJ, Tucker G, Price K, et al. Self-reported

Patients are also being encouraged to take an active role in

to incorporate patients in medication reconciliation and early

Finally, hospitals are increasingly recognizing the crucial role

Although patient engagement is a promising strategy for error

Patients' Role in Precipitating Errors

patients may engage in intentionally unsafe behavior, more

This project was funded under contract number

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