Tuesday, February 9, 2010

Want to Prevent Errors? Kairol Has a Ribbon for You!

One of my favorite patient bloggers has a great post up today. Kairol Rosenthal at Everything Changes shares important things about what patients can do to help prevent medical error. Check out How Do You Prevent Errors in Your Care?

Campaigns that help patients become more active, more visible in their care are on the rise. The Joint Commission has one I like: Speak Up. The focus of campaigns like these--rightly, I think--is on behaviors patients and caregivers should engage in. But it's interesting to know the science behind the recommendations.

Patients are the last line of defense in a complex system of care. Ideally, errors are prevented (through strong system design and rigorous adherence to the processes designed to avert human error). But the next-best thing to preventing an error is to detect it and mitigate negative consequences before the error reaches and harms a patient. This is why the patient's (or advocate's) voice is so important. They are the last line of defense that can detect an error that's been set in motion. Knowing what to expect helps people recognize when things are not going as expected.

For example, asking "Did you wash your hands?" helps avert a common error of omission set in motion close to the patient. Errors arising close to the point of care are particularly hard to detect. (They stand in contrast to things like a physicians' prescribing error which--while potentially serious--routinely undergoes scrutiny by pharmacists and, in a hospital setting, nurses.) The likelihood of detecting and correcting an upstream error (like a wrong dose or wrong drug prescribing error) is good. The likelihood of detecting a downstream error (like failure to perform hand hygiene) is not.

Many clinicians are working to change cultural norms in their workplaces, things that discourage patients and professionals from speaking up when they have a concern about how care is unfolding.  It's a viable strategy that helps cure a healthcare epidemic.

Kairol thinks they should be wearing a ribbon.


Stephanie Jewett, RN, MBA said...

Excellent post and very good site! I am also a RN, MBA from Iowa and look for sites that I admire - I would be interested in exchanging links if you allow that. Stephanie

INQRI Program said...

This is a great post and thanks for the link to Kairol's site. We posted today about the patient's contributions to quality... great minds.

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