Alan B. K. Rabinowitz, administrator of the Patient Safety Authority, said this important consumer information will help patients become more involved in their healthcare by encouraging them to ask questions, become informed, and advocate for themselves and their loved ones. The brochure was reprinted by the Patient Safety Authority with permission from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

“By following this advice, patients can take more control of their treatment and develop a more equal partnership with their healthcare providers,” Rabinowitz said. “For the most part, the relationship between patient and doctor has traditionally followed a parent-child paradigm, and many patients have felt intimidated by their healthcare providers. This brochure and information on the new “Tips for Consumers” web page will help patients and their families know what questions to ask before undergoing any treatment, surgery or hospital stay.”

Rabinowitz added the new web page also includes brochures and other consumer information from a number of healthcare and consumer groups, and includes research conducted by the Patient Safety Authority on the importance of involving patients in healthcare decision-making. An article published in the Patient Safety Advisory, a clinical journal issued by the Patient Safety Authority, shows real-life cases in Pennsylvania where patients or loved ones spoke up and helped prevent medical errors while they were in the hospital. For example:

• A nurse was providing education to a patient and spouse prior to flushing a PICC line [similar to an IV]. When the nurse mentioned [the drug] Heparin, the patient’s spouse spoke up and said that the patient was allergic to Heparin. The nurse reviewed the chart and found no Heparin allergy documented. The allergy had been documented in the patient’s transfer record but had not been transcribed onto the chart. New orders were obtained for flushing this patient’s PICC line using saline only.

• An operating room schedule indicated that a young patient was to have his tonsils and adenoids removed. However, the patient’s parent stated that the child was to have a tube removal, excision of polyp and application of a tympanic membrane patch. An investigation revealed that the initial order from the surgeon’s office was incorrect. Clarifications were made, and the correct procedure was performed.

• A patient’s husband approached nursing staff asking if “that band is still supposed to be tied so tight around her arm.” When the patient’s IV had been started two hours earlier, the nurse had forgotten to remove the tourniquet.

In these examples, having a family member act as an advocate helped prevent medical errors that could have resulted in patient harm. The article, entitled “When Patients Speak- Collaboration in Patient Safety,” was originally printed in the March 2005 issue of the Patient Safety Advisory. To see the entire article, click here.

Patient Safety Awareness Week is a national observance sponsored by the National Patient Safety Foundation (NPSF) as an education and awareness-building campaign for improving patient safety at the local level. The theme of this year’s commemoration, which is the 5th national observance of the event, is “Our Patients- Our Partners: One Team, One Goal.” NPSF has made available literature, videos, handouts and other material to assist healthcare institutions and professionals in encouraging patients to become more actively involved in their healthcare.

Also as part of Patient Safety Awareness Week, the Patient Safety Authority is co-sponsoring a Patient Safety Symposium with the Hospital and Healthsystem Association of Pennsylvania. More than 350 hospital patient safety officers and other quality managers are expected to participate in this all-day conference on Thursday, March 9, 2006. The Authority is sponsoring the keynote address by David Marx, a nationally recognized safety expert from Plano, Texas, who will speak on “Just Culture,” a concept that balances individual accountability with systems failures.

“Patient safety is a complex issue that involves all members of the healthcare community,” Rabinowitz noted. “From hospital administrators and trustees to physicians, nurses and other professionals to patients and their loved ones, everyone has a role in assuring patient safety. During this special observance, we hope that all Pennsylvania healthcare facilities and providers will engage consumers in the delivery of care.”

For the “Tips for Consumers” webpage click here. For the “SPEAK UP™” brochure, click here. For more information about the Authority and other brochures go to the Authority’s website, www.patientsafetyauthority.org. More information about Patient Safety Awareness Week is available at www.npsf.org.

BACKGROUND

 The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, birthing centers and ambulatory surgical facilities are required to report what the Act defines as “Serious Events” and “Incidents” to the Authority. More than 445 healthcare facilities are currently subject to Act 13 reporting requirements.

Facilities submit reports of serious events and incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.

More than 265,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Ninety-five percent of these reports are Incidents or “near-misses.” Based on those reports, the Authority issues quarterly Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm. Occasionally, if reports are submitted that demand immediate attention, a Supplementary Advisory focusing on that one particular topic will be issued.

For more information on the Patient Safety Authority, PA-PSRS or previous Patient Safety Advisories, visit the Authority’s website at www.patientsafetyauthority.org.

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