I believe that the perspective of the patient is an important piece of
the puzzle regarding whether an adverse event has occurred. I do think that
patient’s must play a more active role in their health care by actively listen,
asking questions, and critically thinking when someone is caring for them. As a
health care provider, a majority of my patients do not ask me questions when I
am caring for them. They acquiesce quite easily and favor for the procedure to
be completed quickly. I can understand from their perspective that they do not
want to be of a burden and be rude to those who is caring from them. But should
an adverse event occur; the patient’s perspective can help prevent future
mistakes from occurring again. Also, we must recognize that most adverse events
are results from processes or systematic breakdown and not from a single
source; “Blaming and punishing an individual and failing to change the process
do not reverse the harm that has occurred and do nothing to decrease the
likelihood of the same adverse event occurring again elsewhere in the
organization” (Ransom, Joshi, Nash, & Ransom, 2008).
But the power of patient’s voicing their opinion is often overlooked.
The Joint Commission established “Sentinel Events” for accredited organization;
these are mandatory reporting for certain types of adverse events such as:
infant abduction, suicide, radiation therapy to the wrong body region, or
surgery on the wrong individual or wrong body part. This regulation was intended
to increase accountability and is still use today. But for minimal or harmless errors,
little to no reporting was done because there was no incentive in doing so (monetary
returns) compared to a sentinel event. These “small” errors will likely remain
unchanged and the likelihood for improvements will be nil. That is why patients
must help voice any problems large or small by filling out surveys or reporting
it directly to management, we cannot eliminate all human error but we can help minimize
it; “When safety is part of everyone’s daily routine, errors exist but adverse
events do not” (Ransom et al., 2008). We should not be fearful when making
mistakes because errors will occur, it is how we learn and we must create a
system in which human factors and safety are integrated together, only then we
can fully approach solving patient safety.
Bibliography
Ransom, E. R., Joshi, M. S., Nash, D. B., &
Ransom, S. B. (2008). The Healthcare Quality Book Second Edition.
Chicago: Health Administration Press.
