Pa Patient Saf Advis 2014 Mar;11(1):23-9.
Improvement of Pennsylvania Healthcare Consumers’ Awareness of Patient Safety
Infectious Diseases; Nursing
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Author
Jesse Munn
Managing Editor, Pennsylvania Patient Safety Advisory
Operations Manager, Pennsylvania Patient Safety Authority

Abstract

In the past, the Pennsylvania Patient Safety Authority has sponsored questions in annual, statewide polls of Pennsylvania consumers; specifically, questions to measure consumers’ engagement in patient safety practices (e.g., confirmation of patient identity). In 2013, 604 randomly selected participants were surveyed about their respective engagement in 10 consumer patient safety practices. The Authority first contributed questions about these select practices for the 2006 poll. Authority analysts compared participant responses to the respective polls and observed statistically significant increases in likelihood of engagement in 8 of the 10 practices. Analysts also reviewed consumers’ inclinations to engage in these practices. The 2013 participants were most inclined toward asking for an explanation for understanding, questioning unfamiliar drugs or reasons for procedures, and seeking second opinions about healthcare, and participants were least inclined toward asking about handwashing. Overall, results indicate that the patient safety movement in Pennsylvania is raising awareness of patient safety among Pennsylvania healthcare consumers.

Introduction

The Pennsylvania Patient Safety Authority has been involved with multiple collaborative efforts that included means to increase healthcare consumers’ (i.e., patients) awareness of patient safety issues such as patient identification. In one such collaboration between the Authority and Pennsylvania healthcare facilities that resulted in a 37% aggregate, statistically significant decrease in specimen labeling errors, participating facilities made use of Authority-sponsored “Did You ID Me?” shirt buttons and posters to promote consumer awareness about patient identification.1,2 Accompanying the materials released as part of the Authority’s wrong-site surgery prevention collaborative improvement projects3 is a brochure for surgeons or facilities to provide to preoperative patients so that they understand why their different providers repeat similar questions (e.g., “What is your name?”). An additional, well-known example was the collaborative effort in Pennsylvania to standardize meanings of color-coded wristbands on patients and reduce patient and staff confusion.4 This effort followed an Authority-sponsored survey seeking additional information about facilities’ interpretations of wristbands, initiated after a Pennsylvania healthcare facility reported to the Authority a near-miss involving confusion associated with a colored wristband.5

In other efforts targeted directly at consumers, the Authority hosts on its website more than 30 Consumer Tips that inform patients and caregivers about how to engage in patient safety during the receipt of healthcare (e.g., prevention of medication errors, healthcare-associated infections, misdiagnosis), and the Authority distributes these tips during legislature-sponsored expositions. Most recently, the Authority Board of Directors made “Increase Integration of Patient Voice into Authority Activities” a project as part of its strategic plan, which includes among its objectives to identify and test targeted strategies to engage providers and patients to implement Authority (patient safety) recommendations.6

The Authority is invested in these consumer engagement efforts, and it is in good company. Sister agencies in the commonwealth strive toward similar goals, and at a national level, well-known initiatives include among them the Joint Commission’s Speak Up campaign,7 the National Patient Safety Foundation’s Ask Me 3 program,8 and the Agency for Healthcare Research and Quality’s (AHRQ) “Questions to Ask Your Doctor.”9 Because such efforts, mature or otherwise, target patient awareness and involvement in healthcare, it is important to measure whether awareness is improving or requires more attention. The Authority has previously participated in statewide polls of Pennsylvania residents. In 2006, the Authority sponsored survey questions10 to assess Pennsylvania healthcare consumer engagement in patient safety practices. In 2013, the Authority again sponsored survey questions about Pennsylvania healthcare consumers’ engagement. Comparative analysis of the responses indicates an increase in the likelihood of Pennsylvania consumer engagement in consumer patient safety practices.

Methods

From March 4, 2013, through March 26, 2013, the Penn State Harrisburg Center for Survey Research conducted a random telephone poll of 604* adults in Pennsylvania. The overall survey included base demographic questions followed by specific questions provided by poll sponsors, including the Authority. Associated with the Authority’s poll sponsorship, participants were surveyed about their respective engagement in 10 consumer patient safety practices. These practices were chosen during conduct of the annual poll in 2006 and were included because of their promotion in educational materials targeting consumer involvement in patient safety improvement efforts, as well as their inclusion in past surveys of a similar nature by various other organizations.10

Consumer engagement was measured by asking the following questions about these 10 safety practices:

In regard to your healthcare, how likely are you to

  1. ask a healthcare worker if they have washed their hands?
  2. ask a healthcare worker to confirm your identity before performing a procedure?
  3. seek a second opinion regarding an important healthcare decision?
  4. ask a healthcare worker to explain more fully something they just said that you don’t understand?

How frequently do you engage in the following practices related to your healthcare?

  1. Check that you received the right drug and strength before leaving the pharmacy.
  2. Call your doctor when you have a medical test ordered and no one calls you with the results.
  3. Take a written list of all the medications you are currently taking when going to the doctor.

If you were a patient in a hospital, how likely are you to

  1. question the reason for a procedure before it is performed?
  2. question medications or pills if you do not recognize them and never took this medication in the past?
  3. refuse care, such as an x-ray or drawing blood, that you were not told about by your doctor or nurse?

The sample included landline and cell phone numbers selected at random from Pennsylvania databases, including working, nonworking, and unassigned numbers, to ensure equal chance of selection during the poll process.11 A randomized selection technique ensured every adult age 18 or older within the samples had equal probability of selection. The completed interviews comprised approximately 83% landline and 17% cell phone participants. The completed interviews required placing 12,749 calls of 5,035 landline numbers and 4,521 calls of 2,551 cell phone numbers. For the overall sample size, the sampling error is 4.0% for a 50/50 distribution of responses. The survey cooperation rate for landline responses was 76.8%, and the cooperation rate for cell phone responses was 57.2%. Accounting for frame overlap through weighted rates, the overall cooperation rate was 65.7%.

General demographics of respondents are included in the Table.

Table. Demographic Distribution of 604 Survey Participants in the 2013 Penn State Poll* ​ ​
Variable Number Percentage
Gender
Male29048.0
Female31452.0
Age Category
18 through 24 years7612.6
25 through 34 years9215.2
35 through 44 years10116.7
45 through 54 years11819.5
55 through 64 years9716.1
65 through 74 years599.8
75 years of age or older609.9
Race
White alone51585.3
Black, African American alone437.1
Asian alone111.8
American Indian or Native Alaskan alone30.5
Some other race alone213.5
Two or more races111.8
Region (Counties)
  1. (Allegheny, Armstrong, Beaver, Butler, Fayette, Greene, Indiana, Lawrence, Mercer, Somerset, Washington, and Westmoreland)
14824.5
  1. (Crawford, Erie, Venango, and Warren)
264.3
  1. (Cameron, Clarion, Clearfield, Elk, Forest, Jefferson, McKean, and Potter)
284.6
  1. (Bedford, Blair, Cambria, and Huntingdon)
244.0
  1. (Centre, Clinton, Juniata, Mifflin, Snyder, and Union)
213.5
  1. (Bradford, Carbon, Columbia, Lackawanna, Luzerne, Lycoming, Monroe, Montour, Northumberland, Pike, Sullivan, Susquehanna, Tioga, Wayne, and Wyoming)
7612.6
  1. (Adams, Cumberland, Dauphin, Franklin, Fulton, Lancaster, Perry, and York)
7211.9
  1. (Berks, Lebanon, Lehigh, Northampton, and Schuylkill)
6811.3
  1. (Bucks, Chester, Delaware, Montgomery, and Philadelphia)
14023.2
Source: Center for Survey Research Penn State Harrisburg. Spring 2013 Penn State poll: report of methods and findings. Harrisburg (PA): Penn State Harrisburg; 2013 May.
* Respondent numbers represented in this table may not add up to 604 due to exclusion of "don't know" and "declined to answer" responses.

 

To observe differences in participant responses to the questions about the 10 safety practices, Authority analysts compared the participant responses in the 2013 poll11 with the responses of the 2006 poll (856 interviews).10,12

Following analysis, Authority analysts conducted a search for medical literature in the last five years addressing patient engagement in patient safety. Databases and resources searched included PubMed, Scopus, Google Scholar, Embase, ECRI Institute, and AHRQ. Statistical methods included the chi-square test for linear trend and the Wilson score method13 for proportions.

_______________
* Respondent numbers represented in this article may not add up to 604 due to exclusion of "don't know" and "declined to answer" responses.

Results

Consumer Patient Safety Practices

Comparing 2013 poll results with 2006 poll results, there were statistically significant increases in likelihood of consumer engagement in 8 of 10 consumer patient safety practices (see Figure 1). The two practices that did not demonstrate a statistically significant increase were of the question set about “How frequently do you engage in the following practices related to your healthcare?”

  • Check that you received the right drug and strength before leaving the pharmacy.
  • Call your doctor when you have a medical test ordered and no one calls you with the results.

Figure 1. Likelihood of Consumer Engagement in Consumer Patient Safety Practices, 2013 and 2006 (Statistical Significance Determined by Chi-Square Test for Linear Trend)

Statistical significance was determined by chi-square test for linear trend.

Similar to the 2006 poll results,10 2013 poll participants responded with varied inclination to engage in the 10 patient safety practices. In Figure 2, participants who indicated they were “likely” or “very likely” to engage in a select practice or would “always” or “often” engage in a behavior were combined according to practice and ranked according to 2013 results. In 2013, positive inclination improved by percentage in 9 of 10 practices compared with 2006 (see Figure 1), although, as noted above, overall responses were not statistically significant in 2 practices. Confidence intervals for the proportions were calculated by the Wilson score method without continuity correction.

Figure 2. Consumer Safety Practices, 2013 and 2006, Ranked by 2013 Percentage of Participants Who Were Positively Inclined 

Discussion

Results of the 2013 poll, particularly the statistically significant increases in likelihood of engagement in 8 of the 10 practices, indicate that the patient safety movement in Pennsylvania is raising awareness of patient safety among Pennsylvania healthcare consumers.

The 2013 participants were most inclined (i.e., from 81% to nearly 96%) toward asking for an explanation for understanding, questioning unfamiliar drugs or reasons for procedures, and seeking second opinions about healthcare. These inclinations were consistent with results of the 2006 poll10 in that these four practices were those for which 2006 participants were most inclined (i.e., from 73% to 91%). In 2013, fewer participants, but nevertheless the majority by percentage (i.e., from 50% to nearly 64%), were inclined to call for test results, check drugs before leaving the pharmacy, ask for confirmation of identity, refuse care, and take a list of medications to a doctor’s visit.

Noting that differences in overall 2013 responses were not statistically significant from 2006 responses for (1) checking drugs before leaving the pharmacy or (2) calling for medical test results, analysts reviewed the Authority authors’ discussion of the ranked inclination of 2006 results. For example, there remains a marked difference in proportion of responses of a patient in a hospital questioning medications he or she did not recognize (2013: 90.1%; 2006: 84.3%) and whether a patient would check drugs before leaving the pharmacy (2013: 61.1%; 2006: 63.0%). Authority authors previously noted that patients’ familiarity with their community pharmacy and/or with the routine medications they purchase may breed confidence in these interactions or that there is a consumer belief that medications used in the hospital are associated with more risk than those in the community.10 These beliefs may well persist.

Similarly, regarding no significant change in participant responses to calling for medical test results, Authority authors previously noted the 2006 finding was generally consistent with other study findings at the time, although differences in the survey questions made comparisons difficult.10 In a more recent, cross-sectional, exploratory study of medical and surgical students in a London hospital, Davis et al. found an average response of 6.8 (1: strongly disagree; 7: strongly agree) among patients asked whether they would notify a doctor if they had not received the results of a medical test.14 Notably, there exist differences in population samples, population locations, and scale of responses between this study and the Penn State polls.

Included among the ranked inclination observations, positive inclination of “In regard to your healthcare, how likely are you to ask a healthcare worker to confirm your identity before performing a procedure?” improved by 3 positions among the 10 ranked practices, or a difference of 16.3%. In a previous article about the 2006 poll,10 Authority authors noted low inclination (39.5%) for this practice, potentially warranting patient and family education. National and Authority focus on confirmation of patient identity has continued since the 2006 poll. For example, improving patient identification has been one of the Joint Commission’s National Patient Safety Goals (NPSGs) since NPSGs were enacted in 2003 and is required by all Joint Commission–accredited healthcare organizations.15,16 Further, patient identification forms a core issue of several Authority collaborative improvement projects past and present (e.g., color-coded wristbands, wrong-site surgery, blood specimen mislabeling), as well as featuring among risk reduction strategies for healthcare providers in the Authority’s Pennsylvania Patient Safety Advisory.3-5

The 2013 poll participants, similar to 2006 participants, remained least inclined toward asking about handwashing; however, this consumer practice demonstrated the second greatest percentage improvement in 2013 since the 2006 poll. The medical literature abounds with information about patients questioning healthcare providers about their hand hygiene before patient treatment. In a systematic review of patient safety practices, Berger et al. addressed interventions encouraging patient engagement in patient safety practices, including hand hygiene.17 In one included study addressing hand hygiene, 80% to 90% of patients reported willingness to ask providers to wash their hands, but only 60% to 70% actually questioned providers, suggesting barriers (e.g., fear of negative reaction by providers). Another included study noted that patient factors (e.g., extrovert patient personality, awareness of risk of healthcare-association infections) were associated with patients encouraging providers to wash their hands. Because willingness to engage in the practice remains the lowest of surveyed practices in the 2013 poll, focused attention to patient engagement in provider hand hygiene may still be warranted.

In a systematic review published in 2010 about evidence of patients’ attitudes toward engagement in error prevention, as well as the effectiveness of efforts to increase patient participation, Schwappach notes considerable variation in patients’ attitudes about engaging in “specific, commonly recommended error prevention strategies.”18 Behaviors that require questioning medical authority are less likely than behaviors involving “traditional roles,” such as patients communicating information to their healthcare providers. Such division of the participants’ responses to the consumer engagement practices was noted in the 2006 poll results.10 In the 2013 results, behaviors that directly challenge actions of healthcare providers do not number among the practices with most inclination, but improvement since the 2006 poll is visible nonetheless.

Conclusion

Pennsylvania healthcare consumers were previously reported as being inclined to engage in practices to promote their own safety,10 which continued in results of a 2013 poll. Their inclination varied among the 10 safety practices but was somewhat consistently divided between communicating or seeking information from providers and questioning or challenging providers. There was a noted increase in the likelihood of Pennsylvania consumer engagement in consumer patient safety practices, and overall, it appears the patient safety movement in Pennsylvania is raising awareness of patient safety among Pennsylvania healthcare consumers.

As to whether overall attention needs to continue for consumer engagement in patient safety practices, patient participation in safety practices may be influenced by self-perception and patient-physician relationships, among other factors, and examination of the reaction of physicians and healthcare providers to patient and family engagement may prove beneficial.17 Specifics about patient engagement beyond that of questioning provider behavior may require further study, such as on the optimum strategy for implementation.17 Similarly, a 2013 viewpoint article in the Journal of the American Medical Association noted that while such engagement is unproven, it nevertheless may be valuable to facilitate communication between patients and providers, particularly physicians.19 Overall, the viewpoint states, question-like engagement is a start, and the goal is a more patient-centered experience in which providers engage in open dialogue with patients and minimize “apprehensive silence.”

Acknowledgments

Jonathan R. Treadwell, PhD, associate director, Evidence-based Practice Center, ECRI Institute, and William Marella, MBA, program director, Pennsylvania Patient Safety Authority, consulted on and contributed to statistical testing for this article.

Notes

  1. Reducing errors in blood specimen labeling: a multihospital initiative. Pa Patient Saf Advis [online] 2011 Jun [cited 2014 Jan 15]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/jun8(2)/Pages/47.aspx
  2. Shetterly M. Blood specimen labeling collaborative: path to results. Pa Patient Saf Advis [online] 2011 Jun [cited 2014 Jan 15]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/jun8(2)/Pages/53.aspx
  3. Pennsylvania Patient Safety Authority. Preventing wrong-site surgery [online]. [cited 2014 Jan 15]. http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/PWSS/Pages/home.aspx
  4. Pennsylvania Patient Safety Authority. The color of safety [online]. [cited 2014 Jan 15]. http://patientsafetyauthority.org/EducationalTools/
    PatientSafetyTools/wristbands/Pages/wristband_manual.aspx
  5. Use of color-coded patient wristbands creates unnecessary risk. PA PSRS Patient Saf Advis [online] 2005 Dec [cited 2014 Jan 15]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2005/dec14_2(suppl2)/Pages/dec14;2(suppl2).aspx
  6. Pennsylvania Patient Safety Authority. 2012 annual report [online]. 2013 Apr 31 [cited 2014 Jan 15]. http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/Annual%20Report%202012%20.pdf
  7. Joint Commission. Speak Up initiatives [online]. [cited 2014 Jan 15]. http://www.jointcommission.org/speakup.aspx
  8. National Patient Safety Foundation. Ask Me 3 [online]. 2014 [cited 2014 Jan 28]. http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3
  9. Agency for Healthcare Research and Quality. Questions to ask your doctor: questions are the answer [online]. 2012 Sep [cited 2014 Jan 15]. http://www.ahrq.gov/patients-consumers/patient-involvement/ask-your-doctor/index.html
  10. Marella W, Finley E, Thomas AD, et al. Health care consumers’ inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania. J Patient Saf 2007 Dec;3(4):184-9.
  11. Center for Survey Research Penn State Harrisburg. Spring 2013 Penn State poll: report of methods and findings. Harrisburg (PA): Penn State Harrisburg; 2013 May.
  12. Center for Survey Research Penn State Harrisburg. 2006 Penn State poll: technical report. Harrisburg (PA): Penn State Harrisburg; 2006 Dec.
  13. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998 Apr 30;17(8):857-72.
  14. Davis RE, Sevdalis N, Vincent CA. Patient involvement in patient safety: how willing are patients to participate? BMJ Qual Saf 2011 Jan;20(1):108-14.
  15. ECRI Institute. Patient identification. Healthc Risk Control 2007 Nov;Suppl A:Risk and quality management strategies 16.
  16. Joint Commission. 2014 National Patient Safety Goals slide presentation [online]. 2014 Jan 3 [cited 2014 Jan 15]. http://www.jointcommission.org/2014_national_patient_safety_goals_slide_presentation
  17. Berger Z, Flickinger TE, Pfoh E, et al. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review [online]. BMJ Qual Saf 2013 Dec 13 [cited 2013 Dec 16; epub ahead of print]. http://qualitysafety.bmj.com/content/early/2014/01/16/bmjqs-2012-001769.long
  18. Schwappach DL. Review: engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev 2010 Apr;67(2):119-48.
  19. Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome “white-coat silence.” JAMA 2013 Jun 12;309(22):2325-6.
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