Aug 27th Chat – Patient Safety Continued


Blog post by Colin Hung

Last week we had a record-breaking #HCLDR chat on the topic of medical mistakes and how we can talk about them more openly. We were very honored to have Dr. Brian Goldman as a special guest and the chat was expertly led by Lisa Fields. You can view a transcript of the chat here courtesy of our friends at

During the chat, a few questions and ideas came up that I believe would be interesting to explore further.

  • T1: Should patient safety stats be publically disclosed by HCPs and practices? If so, what data? If not, why not?
  • T2: What can healthcare leaders do to help staff & providers recover/learn from medical errors & adverse events?
  • T3: What role, if any, does social media play in patient safety or medical errors?

Topic 1 – Disclosure of Patient Safety Stats
Many states mandate that healthcare providers submit information about certain adverse events that occur. The type, volume and level of detail of the information collected varies tremendously by state. One state, Pennsylvania, has been collecting and disseminating adverse event information for many years and is considered a leader in this area.

To date, Pennsylvania’s PA-PSRS program has collected and analyzed over 1.8 Million adverse events and has come up with some very interesting insights. If you are interested in patient safety, I highly recommend their Annual Report. The PA-PSRS program is rooted in the desire to learn from all the adverse events that happen across the entire state of Pennsylvania. It was not a program designed to shame/highlight hospitals or other facilities that were poor performing. So far, the state government has resisted the calls on them to use the data in this way.

In 2011, however, the Centers for Medicare and Medicaid Services (CMS) decided to create hospital comparison tool for consumers to use that used patient safety and other quality metrics that it collects. For a full list of metrics, click here.

The question is, should this type of patient safety data be made public? Does it actually help people make better decisions or does it just confuse things? For example, if the data isn’t adjusted for severity of patient demographics then a high mortality rate for a particular disease may not mean that the hospital is a poor performer, it may mean that they just have a patient population that has a higher prevalence of that disease. On the other hand, if we all had this information we could at least ask the facility relevant questions so that we can make the right choice.

Topic 2 – Recovering from an Adverse Event
In the chat last week, there were two tweets about the impact that adverse events have on healthcare providers that I thought were poignant:

CRICOTweet - Patient Safety

This is a caption. This is a caption.

It’s very true that the doctors, nurses, caregivers and administrators involved in adverse events and other patient safety issues are often overlooked. Personally, my eyes were opened when I read Linda Kenney’s story. Linda is the founder of Medically Induced Trauma Support Services (MITSS) and in 1999 she experienced an adverse event while she was in for a “routine” surgery. What makes Linda’s story unique is what happened in the aftermath of the event – both Linda and the anesthesiologist involved in the event connected with each other so that each could talk about what happened. That conversation allowed both provider and patient to begin their personal healing process. You can read more of their story in the Patient Safety and Quality Healthcare article Linda and Dr. Rick van Pelt published in 2005.

Linda, through her organization, has gone on to help many patients, families and healthcare providers recover from the emotional strain of adverse events. You can follow MITSS on twitter here.

For topic 2 the question is what can healthcare leaders do to help their staff – especially those directly involved in the adverse event – recover. To paraphrase Dr. Rahul Nayak: “No one wakes up intending to cause harm to a patient”.

Topic 3 – Social Media and Patient Safety
With the explosion of rating sites, such as Patient Safety Score and social media platforms Twitter and Facebook – patients and providers have many new avenues through which they can comment on healthcare safety.

SoulMirror Tweet - Patient Safety

Both the Agency for Healthcare Research and Quality (AHRQ) and The Canadian Patient Safety Institute (CPSI) both use social media to disseminate patient safety information. Their goal is to use social media to educate and bring awareness to the issue of patient safety. You can read AHRQ’s social media statement here and CPSI’s here.

The question is what role can/should social media play in patient safety. Is it appropriate to comment on a provider’s safety or talk about a medical error on Facebook? Should patients and providers trade tweets about patient safety? Should things stay platonic – restricting discussion to trading knowledge and best practices?

The Value of Social Media: The Journey of the BC Patient Safety & Quality Council – BCPSQC

Social media: the next step to enhancing patient safety – HIROC

Pharma Challenges: Adverse Event Reporting and Social Media – Bloomberg

Alleviating “Second Victim” Syndrome: How We Should Handle Patient Harm – AHRQ

Medical error, incident investigation and the second victim: doing better but feeling worse? – BMJ Quality & Safety

Image Source

One comment

  1. […] a blog written by Colin Hung, on our part 1 discussion from August 20th, which can be found here: For this session, Colin Hung monitored the #HCLDR twitter feed while Lisa Fields, our wing […]

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