News: Action Items Aid in Making Patient, Family Engagement a Core Healthcare Value

By Brooke Schmidt

A recent report from the National Patient Safety Foundation’s (NPSF) Lucian Leape Institute, Safety Is Personal: Partnering with Patients and Families for the Safest Care, advocates for patients and families to be active partners in all aspects of their care, as well as in healthcare design and delivery and in policy development and research efforts. The report focuses on the patient and family role in fostering actions and interventions directly related to reducing the potential for harm.

The report’s central message is that enabling patients and families to be respected partners in healthcare—from the exam room to the policy arena—is essential if the U.S. healthcare system is to continue to make progress in patient safety.

While firmly placing responsibility for patient safety on healthcare providers and organizations, the report urges patients, families, and the public to view themselves as full and active members of the healthcare team. The report calls for targeted education and training for healthcare clinicians and staff to give them skills to better engage patients in decisions and management of health problems and to redesign processes and systems to facilitate patient and family partnerships. Mounting evidence, NPSF reports, reveals that patient engagement is a vital contributing component of safe care.

Many of the Institute’s recommendations are not new, rather, the report explains, “They draw from the growing evidence about the power of engagement and seek to build on what we know can work to reduce adverse events.” Recommendations include:

  • For leaders of healthcare systems: Establish patient and family engagement as a core value for the organization.
  • For clinicians and staff: Provide clear information, apologies, and support to patients and families when things go wrong.
  • For policy makers: Develop, implement, and report safety metrics that foster transparency, accountability, and improvement.
  • For patients, families, and the public: Ask questions about the risks and benefits of recommendations until you understand them.

“Many of the barriers to meaningful patient and family engagement can only be overcome if leaders and clinicians support them in becoming confident and effective partners,” said Susan Edgman-Levitan, PA, lead author of the report. “With this report, we hope to influence health leaders and practitioners to act on the evidence and knowledge we already have.”

The report is the product of two roundtable meetings with representatives of patient advocacy organizations, health systems, research organizations, and industry.

Personal stories of safety lapses punctuate the report and bring the issue into focus. One such story comes from a roundtable participant responsible for a pharmacy and its pharmacists who incorrectly labeled chemotherapy medication administered to a 7-year-old girl. The girl’s mother repeatedly asked a nurse if the medication was correct as it looked different than what the child had received before. Three times, the nurse checked the label and told the mother, “Yes.” The label was correct; the medicine inside was not. The child, who had a curable cancer, died as a result of the error. “Together with the pharmacy department team members,” the supervisor shares in the report, “we faced the reality of what we had done and created a short list of terrible things never to be repeated.”

“There is much that we now know about the value of partnering with patients to improve care,” said Lucian Leape, MD, chairman of the Institute and a founder of the patient safety movement. “We believe the time is now for healthcare leaders to move this forward.”

This is the fourth in a series of reports on issues that NPSF’s Lucian Leape Institute has identified as transforming concepts to improve patient safety. The first, Unmet Needs: Teaching Physicians to Provide Safe Patient Care (2010) addresses the need for teaching quality and safety principles in medical education. In 2012, the Institute published Order from Chaos: Accelerating Care Integration, which looks at the problem of fragmented care and possible solutions. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care, released in 2013, details the profound problem of physical and psychological risks to the healthcare workforce. A subsequent Institute initiative will address the need for transparency in healthcare.

The full report is available to download at

Brooke Schmidt is assistant editor of Patient 
Safety & Quality Healthcare.

Schmidt, B. (2014). Action items aid in making patient , family engagement a core healthcare value. Patient Safety & Quality Healthcare, 11(2), 10.