Patients' reports of safety concerns can reveal adverse events that would not be identified otherwise. In this cluster-randomized trial of patient engagement, patient volunteers read and classified incident reports submitted by hospitalized patients enrolled in the study. Following classification by patients, reports underwent a standardized, validated review by multiple researchers to determine if the event constituted a patient safety incident. Overall, about one-third of patient-reported concerns were deemed to be patient safety incidents. Medication safety issues were the most prevalent concerns. The authors conclude that patient reporting of safety events lends a unique and necessary perspective to error reporting. A previous PSNet perspective highlighted the advantages to and limitations of engaging patients in patient safety.

Patient engagement can improve identification and prevention of medication errors. This qualitative study interviewed cardiology patients about their experiences managing medications after being discharged from hospitals in the United Kingdom. The authors described various types of patient engagement in medication management as sources of system resilience.

This study evaluated the implementation of a patient safety intervention. Frontline staff engagement with the intervention was highly variable and the intervention was not implemented as intended across the study sites. These results underscore the challenge of translating patient safety research into practice.

Although patient engagement is widely recommended as a patient safety strategy, its impact on patient outcomes is unclear. In this cluster randomized trial, hospital wards were designated either to receive usual hospital care or to engage patients in safety by providing a questionnaire and an opportunity to report their positive and negative safety experiences. Investigators compared a global measure of safety, which included pressure ulcers, venous thromboembolism, catheter-associated urinary tract infections, and falls, between wards that engaged patients through this intervention with those that did not. While the participating hospital wards were able to collect safety feedback from patients in a feasible and acceptable manner, researchers found no statistically significant differences in safety outcomes in the patient engagement wards and the usual care wards. The authors conclude that evidence is insufficient to recommend this questionnaire-based patient engagement strategy as a way to enhance safety.

The role of patients in promoting their own safety remains controversial. Although some studies have shown that patients are able to identify errors not detected via other means, others have shown that patients may conflate service quality with safety issues. In this feasibility study, authors describe the development and testing of an intervention designed to collect feedback from hospitalized patients about the safety of their care.

Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.

Patients are increasingly encouraged to participate in preventing and reporting errors. This study evaluated three different methods for capturing safety concerns from patients: bedside interviews, a paper-based form, and a patient safety hotline. Face-to-face interviews generated more than twice as many concerns per patient compared with the other strategies.

Patient engagement programs are being widely implemented as means of improving the safety and quality of hospital care, and prior studies have shown that patients can identify safety issues that go undetected by other methods. This study examined the relationship between patient and staff perception of safety and overall safety outcomes by comparing patient perceptions of safety (measured by the Patient Measure of Safety survey), staff perception of safety (measured by the AHRQ Hospital Survey on Patient Safety Culture), and quantitative measures of patient safety events (measured by the NHS Safety Thermometer). The investigators found that both Patient Measure of Safety and Hospital Survey of Patient Safety Culture results were correlated with objective measures of safety, and they appeared to contribute independently to predicting safety outcomes. This study provides further evidence for including patient perspectives in identifying and measuring safety issues.

… such programs. … Harrison R, Lawton R, Perlo J, Gardner P, Armitage G, Shapiro J. Emotion and coping in the aftermath of …

Patients can make unique contributions to identifying safety hazards. This study reports on the validation of the Patient Measure of Safety survey tool, designed to elicit patient perceptions of safety in the hospital environment.

This systematic review identified 13 studies of patient-reported medical errors. However, due to heterogeneity among the study foci, designs, and analytic methods, the authors of this review could not draw any definitive conclusions about the impact patient-reported errors may have on safety efforts.

… it is to assure safe medication reconciliation. … Moore P, Armitage G, Wright J, et al. Medicines reconciliation using a …

This commentary describes an integrated approach to educating medical students about patient safety.

This study empirically demonstrated that different failure mode effect analysis (FMEA) scoring procedures produce different hazard scores and prioritization.

This analysis of voluntarily reported medication errors found that the reports often did not yield useful data. The authors make suggestions, based on error theory, to improve reporting systems to enhance the ease of reporting and the quality of error reports.

… and Effects Analysis and highlights lessons learned. … Ashley L, Armitage G, Neary M, Hollingsworth G. Jt Comm J Qual Patient Saf. …

Committing a medical error can have profound emotional effects on providers, to the point that clinicians have been termed the "second victim" of errors. This systematic review found that feelings of guilt, shame, and loss of confidence were widespread among clinicians after involvement in an error. However, few studies addressed coping strategies for affected professionals, and those that did generally described existing workplace support structures as inadequate. Some studies report that discussion of errors with colleagues is generally beneficial, and institutions have begun to implement innovative curricula and support systems to aid professionals who have been involved in an error.

The practice of double checking medicines before administration did not appear to effectively prevent medication errors. This article supplies recommendations for improving the process, based on interviews with frontline providers.

In this position paper, the author considers the ethical issues involved in error research at National Health Service hospitals.