Can Patient Participation Improve Patient Safety?

Patient Participation: Current Knowledge and Applicability to Patient Safety.

Longtin et al. Mayo Clinic Proceedings; 2010: 85: 53 - 62

Many experts and authoritative organizations such as the Agency for Healthcare Research and Quality, and the American Academy of Pediatrics now recommend that patients and their families should play a role in patient safety. The World Health Organization too -- through the Patients for Patient Safety component of its World Alliance for Patient Safety -- has made patient participation in patient safety efforts a centerpiece of its efforts to promote patient safety globally.

Can patient participation really improve patient safety? To answer this question (and review patient participation in clinical care in general), Longtin and colleagues conducted a literature search on patient participation in care. They found that while patient participation in clinical care (such as in making medical decisions, and in chronic disease management) is fairly well-defined and has been addressed by a significant body of literature, patient participation in patient safety efforts has not been well studied and requires research.

What do patients think about this idea? Over 90% of patients in one survey said that they thought they could prevent medical errors occurring in hospitals, and that hospitals should educate patients about this. However, their willingness to participate in patient safety varied according to how confrontational the exact intervention was. Many patients (84%) were comfortable asking a nurse to verify a patient’s identity, while only 45% were willing to ask staff to wash their hands. In particular, questioning a healthcare worker’s judgment or actions might be unacceptable to patients. 

Much of the existing research on patient safety efforts comes from studies on hand hygiene. In surveys, 70 - 80% of respondents said they would be willing to ask healthcare workers to wash their hands if the action was framed as a theoretical possibility. However, if the question was asked in a more concrete manner (“what would you do if you thought a staff member had not washed their hands?”), only 38% of respondents supported patient participation.

Longtin and colleagues propose that several patient-related factors and healthcare worker-related factors influence patient participation in patient safety. The patient related factors are: Acceptance of new patient role, level of health literacy and extent of knowledge, confidence in own capability, typeof decision making required, stakes of the proposed outcome, legitimacy of the intervention, type of illness and comorbidity, ethnic origin and race, and health care worker professional specialty. The healthcare worker-related factors are: acceptance of the new HCW role, training in HCW-patient relationship, support from the institution, perception of lack of time, professional category, beliefs, demographic variables, and type of problem.

Encouraging patients and their families to monitor patient safety for individual patients might have several undesirable effects. For example, health care workers might feel that they are being ‘policed’ by patients or their families, and resent this. It might place an unduly excessive burden on patients and their families at a time when they are already ill, worried and feeling vulnerable.

 Besides, we should be careful about foisting a ‘one size fits all’ approach onto all patients and families and should not insist that all patients/families participate in patient safety efforts. Many patients and families do not wish to participate, either in clinical decision-making or in patient safety interventions – they prefer to delegate authority and responsibility to health professionals.

This paper provides a useful dichotomy for thinking about how patient participation can improve patient safety – participation at the level of an individual patient, and participation in advisory and policy groups.

The authors of this paper also emphasize that patient participation in patient safety (and overall care in general) requires not just acceptance, but encouragement by healthcare workers. For example, in one study, when health care workers wore badges with an explicit invitation, the challenge rate by patients for hand hygiene increased.

The paper concludes by stating that the use of patient participation to decrease medical errors and to increase staff adherence with optimal practices is promising, and deserves further study, but given the potential obstacles at patient, health care worker, and health care center levels, and given the controversial nature of this subject, rigorous studies on this topic are required.