Patient Safety: Distinct Roles, One Goal

By Jeffrey Brady, MD, MPH, and Tejal K. Gandhi, MD, MPH, CPPS

This week marks the start of Patient Safety Awareness Week, during which we call attention to the importance of patient safety and the myriad ways that health professionals, patients, and families can work together to ensure that every health care encounter is a safe one.

Our organizations — AHRQ, the Institute for Healthcare Improvement (IHI), and the National Patient Safety Foundation (which merged with IHI last year)—together have decades of experience in patient safety that we’ve gained from working with teams throughout health care. We’ve learned a great number of lessons over the years, perhaps most important that everyone has an essential role to play to improve patient safety and protect patients.

We’d like to talk for a moment about the role of patients and their families. As a result of our ongoing patient safety research, we’ve discovered that care is safer when patients and families are actively involved at all levels of the health system. At the most fundamental level, this means participating as an engaged member of their own health care team by asking questions and speaking up about concerns and values.

We realize this role isn’t always a natural one for patients, and we understand why. Barriers can discourage patients from speaking up. These obstacles range from cultural factors (including wrong assumptions or misperceptions about patients’ priorities) to time pressures in busy medical offices and hospitals that pose challenges to inviting questions. But speaking up is so important, and dedicated and determined teams of patients and health care professionals are finding innovative ways to make sure that it happens.

When patients speak up, what should they say? The complexity of modern health care can prompt a wide array of topics to be addressed, but some of the most important communications with patients fall into three broad categories. We know that successful organizations that are serious about shared decision-making and focused on safety encourage patients to:

  1. Ask questions to make sure they understand their diagnosis and treatment options and plans.
  2. Speak up about the risks and problems they see or may encounter.
  3. Express their values.

When patients speak up — and when health care professionals engage and empower them to do so, and then understand and act on what we hear— we strengthen the health care team. Everyone has a role. This includes health systems, enacting policies and establishing expectations and a culture with safety as a priority. This includes clinicians, practicing with respect, both to patients and to each other. And it includes patients and their loved ones, positioned at the center of this team as active participants. Each member of this team has an important contribution, aligned with a common goal—a safe health care encounter.

Over the coming week, we’ll be calling attention to patient safety through a wide variety of outreach. We urge you to participate in Patient Safety Awareness Week as much as possible—and to continue the valuable work that you do to keep patients at the center of care. Dr. Brady is director of AHRQ's Center for Quality Improvement and Patient Safety and an assistant surgeon general in the U.S. Public Health Service. Dr. Gandhi is chief clinical & safety officer of the Institute for Healthcare Improvement.


Dr. Brady is director of AHRQ's Center for Quality Improvement and Patient Safety and an assistant surgeon general in the U.S. Public Health Service. Dr. Gandhi is chief clinical & safety officer of the Institute for Healthcare Improvement.

This blog post originally appeared on the AHRQ blog.


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The Institute for Healthcare Improvement salutes Mallinckrodt Pharmaceuticals for their generous support of this year's Patient Safety Awareness Week.