This article originally appeared in the January 2006 Harvard Health Letter and is provided courtesy of Harvard Health Publications.

Patient, protect thyself?

Studies show that you can, as a patient, spot and possibly prevent a medical error from happening to you.

American medicine used to keep mum on the subject of medical mistakes and the harm they do. Harvard researchers helped break that silence with a 1990 study of adverse events in hospitals throughout New York State. Then the Institute of Medicine put its spotlight on the issue with a 1999 report, To Err Is Human. Scores of studies have been done since, and most have involved identifying errors by reviewing medical records.

Patients bear witness
What about talking to patients? Some researchers have. Harvard researchers studied medication errors at four adult primary care practices in Boston. They interviewed patients twice: once 10–14 days after they received a prescription and then about three months later. Medical records were reviewed separately.

The researchers found that 179 of the 661 patients (27%) believed they’d had medication-related side effects. Doctors reviewed those cases and concluded that 58% of the time the patients had in fact experienced an adverse drug event — that is, some kind of medical symptom or injury caused by a medication.

Hospitalized patients
Some of the same Harvard researchers reported results in 2004 from a similar study — with one key difference: The people they interviewed were hospital patients and their families. There was some question whether hospitalized patients might be too ill, stressed, or unsettled by their strange surroundings to recognize problems, even with the help of family members.

The researchers interviewed a total of 228 people while they were in a Boston teaching hospital and again 10 days after they’d been discharged. The researchers asked the patients and their families about any problems, mistakes, or injuries they’d encountered. Dr. Saul Weingart, the lead investigator of the study and director of the Center for Patient Safety at Harvard-affiliated Dana-Farber Cancer Institute (although the study wasn’t done at Dana-Farber), said the vast majority of patient comments involved “service problems”: long waits, lack of politeness, dirty surroundings, bad food, and so on. As Weingart noted, these are definite shortcomings at any hospital, but they don’t necessarily mean bad care, except in the most extreme cases.

When they winnowed the patient comments down to medical issues, Weingart and his colleagues found that 17 people — 7% of the 228 — experienced an adverse event and 8 more had a “near miss,” in which a mistake was made but no harm was done. Yet some of the close calls were pretty harrowing. For example, one patient fell down in the bathroom and wasn’t discovered for three hours.

Unrecorded, unreported
One especially unsettling fact that has emerged from medical error research is that many errors aren’t recorded in patient charts. In Weingart’s study, for example, nearly half of the adverse events and most of the near misses weren’t in the medical records. Furthermore, not one of the adverse events or near misses was mentioned in the hospital’s incident reports, which are used by health regulators and by hospitals themselves to monitor patient safety.

These two Harvard studies document what many have long known: Patients are pretty good (though far from perfect) at recognizing medical errors. Groups like the American Hospital Association and the National Patient Safety Foundation have called for more patient participation as one way of preventing errors.

But what exactly does patient participation mean? For one thing, telling your doctor if you experience unusual symptoms. In the study of errors at the four adult primary care practices, researchers concluded that about a third of the “ameliorable” adverse events occurred because patients didn’t tell their doctors about their symptoms.

Some experts, though, question whether too much is being expected of patients. Several groups have distributed well-meaning safety “tips” that offer advice on how patients can prevent medical errors. In September 2005, Dr. Troy Brennan, a Harvard Medical School professor and leading authority on medical malpractice, and two colleagues published a critique of such lists. They argue that none were evaluated before they were distributed and that not enough attention was paid to the patient’s perspective as they were being developed.

In this together
They also point out that some tips involve checking or challenging health professionals’ actions — for example, reminding doctors or nurses to wash their hands, or double-checking medication orders. That may be good advice, but, as they noted, it conflicts with the expectations that many people have — and think that health professionals have — of the patient’s role. As patients, we typically want and need to be taken care of. And we certainly don’t want to get a reputation as the dreaded “difficult patient.”

Good, open communication between doctors and patients could stop some errors. That’s most likely to happen when doctor-patient relationships are fairly equal and based on some sort of we’re-all-in-this-together ethos. But even in the best of circumstances, and in all walks of life, true partnerships are difficult balancing acts sustained by hard work — and large measures of trust and caring.