Being treated by a polite doctor can mean the difference between successful or unsuccessful medical care. According to research recently published in JAMA Surgery, the quality of communication between doctors and patients has a major impact on the likelihood of suffering surgical complications, many of which constitute preventable medical mistakes. With medical mistakes now representing the third leading cause of death in the United States, this study is worthy of public attention.
The study documented that patient complaints were directly tied to surgical complications, medical complications, and hospital readmissions. The surgeons with the greatest number of complaints had an adjusted surgical complication rate that was 14 percent higher than those with the fewest complaints. While some complications are not avoidable, many are. Healthcare and regulatory organizations count hospital readmissions as medical mistakes—something that should not have occurred and caused additional harm.
The study authors concluded, “Efforts to promote patient safety and address risk of malpractice claims should continue to focus on surgeons’ ability to communicate respectfully and effectively with patients and other medical professionals.” True, though the importance of respectful communication applies to all healthcare professionals, not just surgeons.
Consider this tragic chemotherapy mix-up that was expressed by a participant in a roundtable discussion hosted by the National Patient Safety Foundation’s Lucien Leape Institute. The mother said, “That doesn’t look like the chemo she has gotten previously. Are you sure it’s right?” She asked again a bit later. And she asked a third time. She was right and her child—who had a curable cancer—died of a chemotherapy mixture error. The nurse confirmed each time that the label on the bag was accurate. And each time, the nurse assured the mother it was the right medication. And she was right—the label said the right thing. But that wasn’t what was in the bag.
Or what about the widely publicized story of 18-month old Josie King recounted in Josie’s Story: A Mother’s Inspiring Crusade to Make Medical Care Safe? As vividly recounted by Sorrel King, Josie’s mother, her daughter died because healthcare providers failed to communicate appropriately. Although one doctor listened to the mother’s concerns about Josie’s signs of dehydration of opiate painkillers and changed her care accordingly, another doctor failed to honor the change without discussing it with Sorrel despite knowing her concerns. Then a nurse rudely rebuffed Sorrel’s repeatedly expressed concern about the medication’s affect on Josie and her stated objection to another dose of the powerful painkiller. It turned out mother knew best—Sorrel King had observed the sort of behavioral changes in her daughter to which medical professionals and lab results are often not equally attuned.
Undoubtedly, patients can play a critical role in decreasing the occurrence of medical errors, but the utmost care must be taken to prevent the perception that the healthcare industry wishes to transfer the burden of responsibility for safety to patients. Yes, hospitals and other healthcare organizations have an obligation to invite patients to engage in the process. However, healthcare organizations cannot demand that all patients become effective partners in safe care nor can they blame patients when they fail to come to the aid of their providers.
Patients are now routinely admonished to speak up for safety, but this nonspecific demand does not constitute genuine patient engagement. Vikki Entwistle, a former Harvard School of Public Health Fellow, argues that many existing information pamphlets that are given to patients in the hope that they will speak up for safety might do more harm than good. For example, telling patients to be ever vigilant and to make sure they have an advocate with them at all times during their hospitalization can set up unrealistic expectations that induce a sense of lingering guilt when things do go wrong. In fact, Josie King died from a preventable medical mistake despite her mother’s nearly round-the-clock presence during her two-week hospital stay.
As a group, healthcare-associated infections, medication administration errors, and surgical and procedural mix-ups represent about half of all preventable medical mistakes. In addition to being prevalent, predictable, and preventable, this group of patient safety events can be avoided with simple, quick, and essentially cost-free behaviors that are performed during almost every patient encounter and in eyeshot of patients—making them a trifecta of sorts.
If the public were to realize that habitual use of simple behaviors could prevent such adverse outcomes, who wouldn’t make sure they were used with their loved ones or themselves? The challenge lies in raising public awareness and getting healthcare professional to consistently use safety habits that sometimes seem too simple to matter.
To engineer wide-scale behavior change we must recognize certain realities. First, improving patient-provider communication and many other aspects of safe care has less to do with figuring out what needs to be done and more to do with figuring out how to get people to do what needs to be done.
Second, it is sometimes easier to get people to act their way into a new way of thinking than to think their way into a new way of behaving. As Aristotle said, “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.”
Third, when a broad segment of the population is affected by a given problem like medical mistakes, workable solutions must involve straightforward and inexpensive actions. Speaking to and working with the people most affected by the problem is often key to discovering pragmatic solutions. A people-driven approach often reveals solutions that would otherwise remain “invisible in plain sight.”
Moreover, because the breadth and volume of healthcare providers who must consistently exhibit the safety habits known to prevent healthcare’s current trifecta and many other medical errors is so great—as is the breadth and volume of citizens who must help them get there—people-driven solutions are imperative.
In the United States, community coalitions represent a people-driven approach that excels at raising public awareness and mobilizing coordinated efforts to engage the public and healthcare providers around specific, desirable, and concrete actions. Community health coalitions bring together diverse groups and individuals to solve pervasive problems. Without taking sole ownership for a broadly defined problem, local coalitions enable organizations to tackle issues through the use of pooled community knowledge and resources. The resulting synergy makes it possible to accomplish goals that no single organization could achieve on its own.
Facilitating respectful communication between patients and providers around any one of healthcare’s current trifecta of patient safety events is tailor-made for community coalition work. As Aristotle would predict, doctors would exhibit more respect for patients if they engaged in specific, scripted behaviors than if they were admonished to be more considerate. Likewise, patients would be more likely to speak up in the face of safety habit oversights after practicing language that is scripted for such incidents than if they received the vague instruction to speak up for safety. Despite the identified need and proven effectiveness of community coalitions, they remain conspicuously absent from the patient safety movement.
For over 15 years, healthcare has been working to reduce medical errors, but there has been little evidence of widespread success. If the industry is serious about transformative improvement, it must begin to promote and support formation of local patient safety coalitions to eliminate infections, medication administration errors, and surgical mix-ups. This may be the only realistic way to ensure patient and provider education is tightly coupled in ways that will result in the desired behavior changes among those who give and received medical care.
Cooper, WO, Guillamondegui, O, Hines, OJ, Hultman, CS, Kelz, RR, Shen, P, et al. Use of Unsolicited Patient Observations to Identify Surgeons With Increased Risk for Postoperative Complications. JAMA Surg. Published online February 15, 2017.
King, Sorrel, Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safer. New York, NY: Atlantic Monthly Press, 2009.
Makary, MA & Daniel, M. “Medical error-the third leading cause of death in the US.” BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139.
National Patient Safety Foundation. "National Agenda for Action: Patients and Families in Patient Safety Nothing About Me, without Me." https://c.ymcdn.com/sites/www.npsf.org/resource/collection/ABAB3CA8-4E0A-41C5-A480-6DE8B793536C/Nothing_About_Me.pdf.
Watson, GL. "The Hospital Safety Crisis: Unifying Efforts of Healthcare Systems, Public Health, and Society," Society 53, no. 4, 2016.
Watson, Gretchen LeFever. Your Patient Safety Survival Guide: How to Protect Yourself and Others From Medical Errors. Maryland: Rowman & Littlefield, 2017 (August 8).