What is Patient Safety?
The term Patient Safety refers to “the absence of preventable harm to a patient during the process of health care.” Patient Safety Awareness Week is a function of the Institute for Healthcare Improvement (IHI), formerly the National Patient Safety Foundation (NPSF), which has been working for more than 25 years to “advance and sustain better outcomes in health and health care across the world” through “awareness of safety and quality” to ensure the best care. Providers and advocacy groups, both civilian and military participate in the awareness initiative by educating their own staff on various topics surrounding patient safety as well as reaching out to their extended community with information and resources.
Previous Patient Safety Awareness Week themes have included #WeAreAllPatients and included tips for patients and caregivers to avoid identification errors in healthcare. The focus in 2021 has four parts:
- Lead a Culture of Safety
- Increase Patient & Family Engagement
- Prevent Patient Harm
- Improve Community Health
Human error is most often found to be the root of mistaken patient identity. As healthcare workers encounter and process an astounding amount of information each day, the opportunity for mistakes is exponential. Between what is ordered, charted, reported, coded, and billed any number of small inaccuracies can cause big headaches. Preventable health care deaths top out over deaths from Alzheimer’s disease, lung cancer, and breast cancer combined each year making health care related deaths the third leading cause of U.S. deaths in 2020. Additionally, these errors cost Americans as much as $20 billion in 2020. Many providers are employing a range of educational programs to prevent these errors and, ultimately, deaths. Health care simulations that allow providers to practice handling scenarios in realistic, high-tech environments show promise, though funding is still a challenge for many of these programs.
What Are the Most Common Health Care Errors?
Many of the boring, ordinary interactions that a patient has with providers can be subject to a number of opportunities for error:
- Inadequate information flow, appropriate communication of orders, tests, and transfer of care.
- Human errors stemming from poor documentation, labeling, knowledge-based errors, or lax standards of care, policies, processes, or procedures.
- Patient-related issues including inadequate patient identification, assessment, failure to obtain consent, and insufficient patient education.
- Organizational transfer of knowledge that can occur with insufficient, inconsistent, or inadequate education for care providers and most often found in new employees or temporary help.
- Staffing patterns and workflow that is inadequate as it can cause errors and place staff in situations where mistakes are more likely to happen.
- Technical failures of medical devices, implants, grafts, or equipment components.
- Inadequate policies can often be traced as a root cause from poor documentation and inadequate or non-existent procedures.
The Problems with Healthcare Data
The issue surrounding access to personal healthcare data has been an obstacle we are still working to overcome. Currently, our data is spread out across medical centers, hospitals, pharmacies, private practices, etc. This data is stored in disparate systems that do not communicate with each other, making the exchange of healthcare information burdensome and inefficient.
Most cases of healthcare error stem from a lack of interoperability in healthcare systems. While interoperability has been a hot topic in healthcare for around a decade, progress is disappointingly slow. Organizations outside of the U.S. have also recognized that the technology surrounding medical data needs to catch up to the public’s expectations. As is so often the case, it will take a groundswell of patients, patient advocates, loved ones, caretakers, and providers to require that those in power commit to real, lasting progress.
What Can Patients Do?
At some point in our lives, we are all either patients or the loved one of a patient. Patients and their support can help in many ways:
- Ask to view your medical records. Correct any mistakes.
- Ensure that each of your providers knows what has been ordered, recommended, or prescribed by any other provider. Verify that this is in your record for each provider.
- Discuss past mistakes that have been made with your provider(s) so that they can not only be corrected, but avoided in the future.
- Join the EHR Data Wavemakers movement and demand the change of healthcare data standards by sharing your #myEHRstory!