Your Patient Safety Survival Guide: How to Protect Yourself and Others From Medical Errors

Book Title: Your Patient Safety Survival Guide: How to Protect Yourself and Others From Medical Errors

Book Author: Gretchen LeFever Watson

Publication Information: Lanham, MD, Rowman and Littlefield, 2017, 204 pp., $33, hardcover, $31 eBook

Gretchen LeFever Watson, PhD, powerfully understands the extent and etiology of medical errors. On the personal side, she endured incomprehensible suffering as a mother sitting at the bedside of her comatose 4-year-old daughter (who ultimately survived and thrives). This grave situation was preventable, and was the result of medical error. On the professional side, Dr LeFever Watson, a clinical psychologist and researcher, has worked for many years as a leader, advocate, and consultant for improved hospital and health care safety.

This background has helped her write a powerful book that takes on three core areas of medical error: hospital-acquired infections, wrong-site surgeries, and medication administration errors. There is something in this book for everyone with interest in this area: horrifying case examples, astounding error prevalence statistics, and very smart empirically-based solutions to these problems. The author masterfully weaves a text that speaks simultaneously to patients, practitioners, and communities. As such, this book will be equally helpful for patients and families anticipating hospital care, and as a teaching tool for students, residents, and practicing clinicians who must embrace sustained attention to prevent even small mistakes that can result in devastating consequences.

In the first two chapters, Dr LeFever Watson presents a historical overview on safety initiatives and emphasizes the importance of patient and community involvement in safety enhancement. She goes on to describe the promise of safety habits training and implementation for health care practitioners and patients, such as speaking up for safety, in which everyone shares responsibility and a voice in error prevention.

Chapters three, four, and five take a deep dive into the problems of preventable infection, wrong-site surgeries, and medication administration errors. Dr LeFever Watson brilliantly combines psychological and social theory and research in helping the reader understand the complexity of the multiple factors that contribute to mistakes. These three chapters each include a very useful table that emphasizes and summarizes key learning points for patients and practitioners alike. Patient action plans included in each chapter would be extraordinarily helpful to bring to the hospital as a patient, and the “What You Can Say” tables provide useful wording for patient and caregiver activation, advocacy, and respectful insistence on careful safety-minded health care practices. For example, the author offers suggestions for patient messaging such as “Sorry I didn’t see you wash your hands. I know it’s important and I’d really appreciate you doing this for everyone’s benefit” (p. 58), and “Wait, before you sedate me, the surgeon has not marked my body with her initials” (p. 81). As an additional gift to the reader, these tables also include examples of optimal responses from the health care practitioner, such as: “Thank you for stopping me. I thought that had been done. I’ll be back after the surgeon has reviewed the procedure with you and marked your body” (p. 81).

Chapter six is a call to action for communities to work in partnership with their local hospitals and health care organizations in the pursuit of active dialogue and organizational change. Chapter seven, titled “Acceptance, Apology and Forgiveness: Safeguard the Lives of Patients and Healthcare Providers” is a particular treasure for medical educators. Here, Dr LeFever Watson clearly articulates the differences between accidents, mistakes, and failures, and speaks compassionately to the medical error pressures faced by health care practitioners, and the experience of having contributed to a preventable tragedy. While the author has highlighted the causal role of work and productivity demand pressures throughout the book, here she builds a strong argument for the importance of self-care, burnout prevention, and the provision of compassionate support to those who have contributed to medical errors. Also in this chapter is a compelling argument for the importance of honest disclosure of mistakes to patients and their families, with attention to the legal and economic aspects of these challenging conversations and situations.

The book does not specifically take on the problem of health disparities, nor the degree to which different groups of patients are perceived and treated differently due to practitioner bias and stereotyping and as such are at heightened risk for medical errors. Thus, the reader may be left hungry for a discussion of comparative rates of medical errors across groups with accompanying recommendations for bias reduction and safety checks to insure equitable and excellent care for all.

Dr LeFever Watson is a champion for safety excellence in our health care system, and she makes a fervent call for clear-eyed, team-based quality approaches to medical error reduction. Undoubtedly readers of this engaging and informative book will be much stronger advocates for and participants in these reductions as patients, family members, and health care practitioners alike.