The Government of England recently passed legislation requiring institutions to inform patients, and/or other appropriate parties, of instances where patients have been harmed as a result of “errors”. The term “error” has always troubled me because it imparts a flavour of blame. Although many patient safety incidents may be due to “errors”, others arise due to system and/or human inefficiencies or insufficiencies; and often numerous contributing factors align in the final causality of harmful incidents.
“Doctor, what would you do if Sally were your child?”
Hospitals are dangerous, encumbered by system inefficiencies and human factors affecting performance. Despite all the hazards in the hospitals we do not generally ask patients to acknowledge this. Patients give consent for many aspects of care by simply agreeing to be admitted.
“What I believe matters a lot.”
When clinicians talk with patients we bring our compassion and knowledge to the table. Patients, our partners in achieving outcomes, bring their knowledge, their apprehensions, their belief systems and their beliefs to the table. We must share our knowledge in order to assure patient safety. Clinicians must listen to patients, and if patients seem reluctant to talk then we must ask probing questions.
Transitions in care represent potential weak links that couple together the complex array of care options that patients may encounter as they traverse the modern healthcare system. Errors in communication can occur at shift changes for nurses and physicians, especially house officers, between units within hospitals (in some systems multiple transfers between wards is the norm) and between facilities. Each of these transitions requires the transmittal of precise relevant information that enables the transition to go smoothly so that errors are anticipated and eliminated, or at least reduced to the bare minimum of risk. Failure to do so can have catastrophic consequences.