In recent years, physicians are breathing new life into this ancient principle. Health-care providers nationwide are taking a new perspective on patient safety by recognizing that safety rests on the systems of care rather than on the shoulders of individuals. Health-care providers are shedding light on how processes and patient outcomes can be improved through better teamwork, open communication and use of information technologies.

An Institute of Medicine report in 1999 helped spur the renewed look at safety issues. The report described the scope of the issue and set a general direction for improvement. The overarching theme was that a cultural shift in how we think about errors is the first step toward eliminating them. Focusing on individuals and individual mistakes is not effective and, in fact, promotes a culture of secrecy. In reality, errors are usually due to the convergence of multiple factors. The best way to improve safety is to refine the processes so errors are less likely to occur.

In 2003, the Joint Commission on Accreditation of Healthcare Organizations released National Patient Safety Goals, including six broad goals with specific recommendations on how to achieve them such as improving the accuracy of patient identification and eliminating wrong-procedure surgery. Health-care providers nationwide are implementing new routines such as a double checking the patient´s name, birth date and medical record number before procedures, and taking a time out before surgery to confirm the patient, surgery site and procedure.

For years, Loyola University Health System has led the way in improving the quality and safety of patient care. Our Center for Clinical Effectiveness is nationally recognized for expertise in improving systems of care. In addition, we are among a handful of medical centers moving to a completely paperless medical environment. Among the benefits of electronic medical records are built-in features that reduce error such as warnings about incorrect drug doses or drug interactions.

Our latest undertaking is updating our physician, staff and student education program on patient safety. We are improving reporting mechanisms so that errors and even near misses can be quickly reported and investigated. Better documentation will help us improve systems of care. We are working diligently to create a “just culture’ where staff members at any level are encouraged to speak up if they have safety concerns and are assured that they will not be blamed for errors caused by systems that are not designed well.

Patient safety is everybody´s business. While health-care providers do their job to ensure safety, there are things you can and should do as well. Here are a few ways that you can get safer health care.

1. Be an informed health-care consumer by researching your treatment options and the providers. Select a doctor and hospital experienced in the care you need.

2. Speak up if you have questions, and ask for clarification if you do not understand the answers. Write down what you have heard about your illness and what you still want to know. If necessary, take a friend or family member who can speak for you when you cannot.

3. Keep a list of your medications that includes the brand name and generic name of each drug, what the drug looks like, how much and how often you take the drug, and any side effects you have experienced. Bring the list with you whenever you see the doctor or pharmacist. Read medication labels, and ask questions if you do not understand something about taking your medication.

4. Be sure to get the results of any test or procedure that was performed. Do not assume that the results are fine if you do not get a call. Ask what the test results mean for your care.

William Barron, M.D., M.M.M., F.A.C.P.
Vice President, Quality and Patient Safety
Loyola University Health System

Patient Safety Web Sites

For more information about how you can ensure your safety, you can consult the following Web sites.

National Patient Safety Foundation

Five Steps to Safer Health Care U.S. Department of Health and Human Services

Twenty Tips to Prevent Medical Errors in Children

Loyola University Health System

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