In this guest blog post in honor of Patient Safety Awareness Week, Dr. Mike Posencheg describes how his experience as a patient has informed his views on engaging patients to improve patient safety. Posencheg is the Medical Director of the Intensive Care Nursery and Newborn Nursery at the Hospital of the University of Pennsylvania. He completed the IHI Improvement Advisor Professional Development Program in 2012.
It was nearly eight years ago, but I still vividly remember awakening after double hip replacement surgery. Two things were immediately apparent to me: 1) my left foot was pointing out to the left while my right foot was pointing to the ceiling; and 2) I was nauseous. While waiting for the results of a routine post-op x-ray, my nausea increased. The last thing I remember was looking at the monitor to see my heart rate in the 40s while lifting my hand to try to get the attention of my nurse or anyone else who could see me.
The next thing I knew, there were people surrounding my bed, and my nurse was thumping on my chest. Shortly after they “welcomed me back,” I learned that my left foot looked funny because my left hip was dislocated. I needed to return to the OR within the hour. I will never forget the stressed look on my wife’s face and the tears streaming down my cheeks as I rolled back down the hallway.
I learned later that both my code event and need for repeat surgery were due to “the level of my anesthesia,” but there are things I noticed during my hospitalization that may also have also contributed. While I have a great relationship with my surgeon to this day, no one ever asked about my view of what happened on that November morning or told me if they reviewed the event in detail to help prevent it from occurring again in the future.
Shouldn’t we do more to engage patients when it comes to patient safety? When police investigate an automobile accident, don’t they speak to the drivers? How many times in a given week do we receive surveys about our purchasing experiences online or in a store? Whether it is to investigate an incident or to improve a product or service, everyone seems to care about the opinion of the customers or participants. It is vitally important that we do the same thing in health care. Our patients have a perspective we can only truly capture by asking them.
But, how do we do it? This is a difficult question to answer because one solution does not fit all clinical environments. For example, my patients can’t tell me what they think since they are all infants, but their parents certainly can. We have found unique ways to engage families in event investigation and our process improvement work at the hospital. In some instances, our patients work elsewhere in the institution. These are the easiest patients to routinely incorporate into your efforts as they already have a vested interest and don’t have to travel far! We have held focus groups with the families of former patients and surveyed current ones. The hospital’s patient safety steering committee also includes two patient representatives. While how we engage patients and families in safety and improvement efforts very much depends on the context, we need their input regardless of the situation.
In quality improvement work, we use the phrase “nothing about us without us” to describe the need to incorporate all relevant disciplines when working on a project. As we celebrate Patient Safety Awareness Week, we need to remember how important it is to include our patients as well.