ATrain Education

 

Continuing Education for Health Professionals

FL: Preventing Medical Errors

Module 7

Public Awareness and Education

 

Although the risk of dying as a result of a medical error far surpasses the risk of dying in an airline accident, a good deal more public attention has been focused on improving safety in the airline industry than in the health care industry.

Institute of Medicine, 1999
To Err is Human: Building a Safer Health System

 

As health insurers have moved toward shifting more healthcare costs to the patient, the public has never been more aware of their role of taking charge of their own care. For example, as of 2014 the final amendments to CLIA give patients the right to receive a copy of their laboratory test reports if requested without waiting for a release from a caregiver (Federal Register, 2014).

Public Awareness of Safety

Patients have greater access to health information than ever before to make sound decisions. Consequently, patients and their families also have a role to play in improvement healthcare quality and safety by being a partner with providers.

AHRQ’s Guide to Patient and Family Engagement in Hospital Quality and Safety (2013c) provides a detailed framework of how hospitals and patients can work together to make care safer. The comprehensive guide makes a number of recommendations, including:

  • Invite two or three patient and family advisors to a hospital staff or committee meeting to discuss their hospital stay. Advisors can share what went well, what could have been done better, and any ideas they have for changes and improvements.
  • At each shift change, shift report happens at the patient’s bedside, and the nurses invite the patient and family or friends to take part in the report.
  • Include the patient and family as full partners in the discharge planning process, reviewing medications, highlighting warning signs and problems, and suggesting what life will be like at home (AHRQ, 2013c).

Public Education on Medical Errors

AHRQ has also developed a list of 20 tips patients can follow to prevent medical errors. Research shows that patients who are more involved with their care tend to get better results.

20 Tips to Help Prevent Medical Errors (AHRQ)

Medicines

  1. Make sure that all of your doctors* know about every medicine you are taking. This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs.
  2. Bring all of your medicines and supplements to your doctor visits. “Brown bagging” your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date and help you get better quality care.
  3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. This can help you to avoid getting a medicine that could harm you.
  4. When your doctor writes a prescription for you, make sure you can read it. If you cannot read your doctor’s handwriting, your pharmacist might not be able to either.
  5. Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them:
    • What is the medicine for?
    • How am I supposed to take it and for how long?
    • What side effects are likely? What do I do if they occur?
    • Is this medicine safe to take with other medicines or dietary supplements I am taking?
    • What food, drink, or activities should I avoid while taking this medicine?
  6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?
  7. If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if “four times daily” means taking a dose every 6 hours around the clock or just during regular waking hours.
  8. Ask your pharmacist for the best device to measure your liquid medicine. For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people measure the right dose.
  9. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does or if something unexpected happens.

Hospital stays

  1. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands. Handwashing can prevent the spread of infections in hospitals.
  2. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home. This includes learning about your new medicines, making sure you know when to schedule followup appointments, and finding out when you can get back to your regular activities. It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital. 

Surgery

  1. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery.
  2. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.

Other steps

  1. Speak up if you have questions or concerns. You have a right to question anyone who is involved with your care.
  2. Make sure that someone, such as your primary care doctor, coordinates your care. This is especially important if you have many health problems or are in the hospital.
  3. Make sure that all your doctors have your important health information. Do not assume that everyone has all the information they need.
  4. Ask a family member or friend to go to appointments with you. Even if you do not need help now, you might need it later.
  5. Know that “more” is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.
  6. If you have a test, do not assume that no news is good news. Ask how and when you will get the results.
  7. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. For example, treatment options based on the latest scientific evidence are available from the Effective Health Care website. Ask your doctor if your treatment is based on the latest evidence.

*The term “doctor” is used to refer to the person who helps you manage your healthcare.
Source: AHRQ, 2015d.

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