R E V I E W S & A N A LY S E S Improvement of Pennsylvania Healthcare Consumers’ Awareness of Patient Safety Jesse Munn INTRODUCTION Managing Editor, Pennsylvania Patient Safety Advisory Operations Manager, Pennsylvania Patient Safety Authority The Pennsylvania Patient Safety Authority has been involved with multiple collab- orative efforts that included means to increase healthcare consumers’ (i.e., patients) ABSTRACT awareness of patient safety issues such as patient identification. In one such collabora- tion between the Authority and Pennsylvania healthcare facilities that resulted in a In the past, the Pennsylvania Patient 37% aggregate, statistically significant decrease in specimen labeling errors, participat- Safety Authority has sponsored ques- ing facilities made use of Authority-sponsored “Did You ID Me?” shirt buttons and tions in annual, statewide polls of posters to promote consumer awareness about patient identification.1,2 Accompanying Pennsylvania consumers; specifically, the materials released as part of the Authority’s wrong-site surgery prevention col- questions to measure consumers’ laborative improvement projects3 is a brochure for surgeons or facilities to provide to engagement in patient safety practices preoperative patients so that they understand why their different providers repeat simi- (e.g., confirmation of patient identity). lar questions (e.g., “What is your name?”). An additional, well-known example was the In 2013, 604 randomly selected par- collaborative effort in Pennsylvania to standardize meanings of color-coded wristbands ticipants were surveyed about their on patients and reduce patient and staff confusion.4 This effort followed an Authority- respective engagement in 10 consumer sponsored survey seeking additional information about facilities’ interpretations of patient safety practices. The Authority wristbands, initiated after a Pennsylvania healthcare facility reported to the Authority a first contributed questions about these near-miss involving confusion associated with a colored wristband.5 select practices for the 2006 poll. Authority analysts compared partici- In other efforts targeted directly at consumers, the Authority hosts on its website more pant responses to the respective polls than 30 Consumer Tips that inform patients and caregivers about how to engage in and observed statistically significant patient safety during the receipt of healthcare (e.g., prevention of medication errors, increases in likelihood of engagement healthcare-associated infections, misdiagnosis), and the Authority distributes these tips in 8 of the 10 practices. Analysts also during legislature-sponsored expositions. Most recently, the Authority Board of Direc- reviewed consumers’ inclinations to tors made “Increase Integration of Patient Voice into Authority Activities” a project engage in these practices. The 2013 as part of its strategic plan, which includes among its objectives to identify and test participants were most inclined toward targeted strategies to engage providers and patients to implement Authority (patient asking for an explanation for under- safety) recommendations.6 standing, questioning unfamiliar drugs The Authority is invested in these consumer engagement efforts, and it is in good or reasons for procedures, and seeking company. Sister agencies in the commonwealth strive toward similar goals, and at a second opinions about healthcare, and national level, well-known initiatives include among them the Joint Commission’s participants were least inclined toward Speak Up campaign,7 the National Patient Safety Foundation’s Ask Me 3 program,8 asking about handwashing. Overall, and the Agency for Healthcare Research and Quality’s (AHRQ) “Questions to Ask results indicate that the patient safety Your Doctor.”9 Because such efforts, mature or otherwise, target patient awareness and movement in Pennsylvania is raising involvement in healthcare, it is important to measure whether awareness is improving awareness of patient safety among or requires more attention. The Authority has previously participated in statewide polls Pennsylvania healthcare consumers. (Pa of Pennsylvania residents. In 2006, the Authority sponsored survey questions10 to assess Patient Saf Advis 2014 Mar;11[1]:23-9.) 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 likeli- hood of Pennsylvania consumer engagement in consumer patient safety practices. METHODS From March 4, 2013, through March 26, 2013, the Penn State Harrisburg Center for In its inaugural “I Am Patient Safety” Survey Research conducted a random telephone poll of 604* adults in Pennsylvania. poster contest, the Authority recognized The overall survey included base demographic questions followed by specific questions individuals and groups within provided by poll sponsors, including the Authority. Associated with the Authority’s Pennsylvania’s healthcare facilities who poll sponsorship, participants were surveyed about their respective engagement in have made a personal commitment to patient safety. For more information, see the article "Commitment to Patient * Respondent numbers represented in this article may not add up to 604 due to exclusion of Safety Recognized in Pennsylvania." “don’t know” and “declined to answer” responses. Vol. 11, No. 1—March 2014 Pennsylvania Patient Safety Advisory Page 23 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 10 consumer patient safety practices. The sample included landline and cell engagement in 8 of 10 consumer patient These practices were chosen during con- phone numbers selected at random safety practices (see Figure 1). The two duct of the annual poll in 2006 and were from Pennsylvania databases, including practices that did not demonstrate a included because of their promotion in working, nonworking, and unassigned statistically significant increase were of educational materials targeting consumer numbers, to ensure equal chance of the question set about “How frequently involvement in patient safety improve- selection during the poll process.11 A do you engage in the following practices ment efforts, as well as their inclusion in randomized selection technique ensured related to your healthcare?” past surveys of a similar nature by various every adult age 18 or older within the — Check that you received the right other organizations.10 samples had equal probability of selec- drug and strength before leaving the Consumer engagement was measured by tion. The completed interviews comprised pharmacy. asking the following questions about these approximately 83% landline and 17% — Call your doctor when you have a 10 safety practices: cell phone participants. The completed medical test ordered and no one calls interviews required placing 12,749 calls of In regard to your healthcare, how likely you with the results. 5,035 landline numbers and 4,521 calls of are you to 2,551 cell phone numbers. For the overall Statistical significance was determined by 1. ask a healthcare worker if they have sample size, the sampling error is 4.0% chi-square test for linear trend. washed their hands? for a 50/50 distribution of responses. Similar to the 2006 poll results,10 2013 2. ask a healthcare worker to confirm The survey cooperation rate for landline poll participants responded with varied your identity before performing a responses was 76.8%, and the cooperation inclination to engage in the 10 patient procedure? rate for cell phone responses was 57.2%. safety practices. In Figure 2, participants Accounting for frame overlap through who indicated they were “likely” or “very 3. seek a second opinion regarding an weighted rates, the overall cooperation rate likely” to engage in a select practice or important healthcare decision? was 65.7%. would “always” or “often” engage in a 4. ask a healthcare worker to explain General demographics of respondents are behavior were combined according to more fully something they just said included in the Table. practice and ranked according to 2013 that you don’t understand? results. In 2013, positive inclination How frequently do you engage in the To observe differences in participant re- improved by percentage in 9 of 10 prac- following practices related to your sponses to the questions about the 10 safety tices compared with 2006 (see Figure 1), healthcare? practices, Authority analysts compared the although, as noted above, overall participant responses in the 2013 poll11 responses were not statistically significant 5. Check that you received the right with the responses of the 2006 poll (856 in 2 practices. drug and strength before leaving the interviews).10,12 Confidence intervals for the propor- pharmacy. 6. Call your doctor when you have a Following analysis, Authority analysts tions were calculated by the Wilson score medical test ordered and no one calls conducted a search for medical literature method without continuity correction. you with the results. in the last five years addressing patient engagement in patient safety. Databases DISCUSSION 7. Take a written list of all the medica- and resources searched included PubMed, tions you are currently taking when Results of the 2013 poll, particularly Scopus, Google Scholar, Embase, ECRI going to the doctor. the statistically significant increases in Institute, and AHRQ. Statistical methods If you were a patient in a hospital, how likelihood of engagement in 8 of the 10 included the chi-square test for linear likely are you to practices, indicate that the patient safety trend and the Wilson score method13 movement in Pennsylvania is raising 8. question the reason for a procedure for proportions. awareness of patient safety among Penn- before it is performed? sylvania healthcare consumers. 9. question medications or pills if you RESULTS do not recognize them and never The 2013 participants were most inclined Consumer Patient Safety (i.e., from 81% to nearly 96%) toward ask- took this medication in the past? Practices ing for an explanation for understanding, 10. refuse care, such as an x-ray or draw- Comparing 2013 poll results with 2006 questioning unfamiliar drugs or reasons ing blood, that you were not told poll results, there were statistically signifi- for procedures, and seeking second opin- about by your doctor or nurse? cant increases in likelihood of consumer ions about healthcare. These inclinations Page 24 Pennsylvania Patient Safety Advisory Vol. 11, No. 1—March 2014 ©2014 Pennsylvania Patient Safety Authority Table. Demographic Distribution of 604 Survey Participants in the 2013 Penn State Poll* were consistent with results of the 2006 VARIABLE NUMBER PERCENTAGE poll10 in that these four practices were Gender those for which 2006 participants were most inclined (i.e., from 73% to 91%). Male 290 48.0 In 2013, fewer participants, but neverthe- Female 314 52.0 less the majority by percentage (i.e., from Age Category 50% to nearly 64%), were inclined to call 18 through 24 years 76 12.6 for test results, check drugs before leav- 25 through 34 years 92 15.2 ing the pharmacy, ask for confirmation of identity, refuse care, and take a list of 35 through 44 years 101 16.7 medications to a doctor’s visit. 45 through 54 years 118 19.5 Noting that differences in overall 2013 55 through 64 years 97 16.1 responses were not statistically significant 65 through 74 years 59 9.8 from 2006 responses for (1) checking 75 years of age or older 60 9.9 drugs before leaving the pharmacy or (2) Race calling for medical test results, analysts reviewed the Authority authors’ discussion White alone 515 85.3 of the ranked inclination of 2006 results. Black, African American alone 43 7.1 For example, there remains a marked dif- Asian alone 11 1.8 ference in proportion of responses of a American Indian or Native Alaskan alone 3 0.5 patient in a hospital questioning medica- Some other race alone 21 3.5 tions he or she did not recognize (2013: Two or more races 11 1.8 90.1%; 2006: 84.3%) and whether a Region (Counties) patient would check drugs before leaving the pharmacy (2013: 61.1%; 2006: 63.0%). 1. (Allegheny, Armstrong, Beaver, Butler, 148 24.5 Fayette, Greene, Indiana, Lawrence, Authority authors previously noted that Mercer, Somerset, Washington, and patients’ familiarity with their community Westmoreland) pharmacy and/or with the routine medica- 2. (Crawford, Erie, Venango, and Warren) 26 4.3 tions they purchase may breed confidence in these interactions or that there is a con- 3. (Cameron, Clarion, Clearfield, Elk, Forest, 28 4.6 Jefferson, McKean, and Potter) sumer belief that medications used in the hospital are associated with more risk than 4. (Bedford, Blair, Cambria, and Huntingdon) 24 4.0 those in the community.10 These beliefs 5. (Centre, Clinton, Juniata, Mifflin, Snyder, 21 3.5 may well persist. and Union) Similarly, regarding no significant change 6. (Bradford, Carbon, Columbia, 76 12.6 Lackawanna, Luzerne, Lycoming, Monroe, in participant responses to calling for Montour, Northumberland, Pike, Sullivan, medical test results, Authority authors Susquehanna, Tioga, Wayne, and previously noted the 2006 finding was Wyoming) generally consistent with other study find- 7. (Adams, Cumberland, Dauphin, Franklin, 72 11.9 ings at the time, although differences in Fulton, Lancaster, Perry, and York) the survey questions made comparisons 8. (Berks, Lebanon, Lehigh, Northampton, 68 11.3 difficult.10 In a more recent, cross-sec- and Schuylkill) tional, exploratory study of medical and 9. (Bucks, Chester, Delaware, Montgomery, 140 23.2 surgical students in a London hospital, and Philadelphia) Davis et al. found an average response of Source: Center for Survey Research Penn State Harrisburg. Spring 2013 Penn State poll: report of 6.8 (1: strongly disagree; 7: strongly agree) methods and findings. Harrisburg (PA): Penn State Harrisburg; 2013 May. among patients asked whether they would * Respondent numbers represented in this table may not add up to 604 due to exclusion of “don’t notify a doctor if they had not received know” and “declined to answer” responses. (continued on page 27) Vol. 11, No. 1—March 2014 Pennsylvania Patient Safety Advisory Page 25 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 1. Likelihood of Consumer Engagement in Consumer Patient Safety Practices, 2013 and 2006 (Statistical Significance Determined by Chi-Square Test for Linear Trend) IN REGARD TO YOUR HEALTHCARE, HOW LIKELY ARE YOU TO 30.3% 42.7% Very likely 19.3% Very likely 30.2% Likely 11.8% Likely 13.1% 6.6% 9.3% Somewhat 19.5% Somewhat 14.7% likely 11.3% likely 9.7% 38.4% Not likely 29.0% Not likely 49.7% at all 62.5% at all 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 ask a healthcare worker if they have washed ask a healthcare worker to confirm your identity before their hands? (statistically significant increase performing a procedure? (statistically significant increase in likelihood, p < 0.0010) in likelihood, p < 0.0010) 2013 61.6% 83.1% Very likely 58.3% Very likely 79.8% 2006 Likely 19.9% Likely 12.4% 15.3% 11.2% Somewhat Somewhat 3.3% 13.4% likely 15.4% likely 4.3% Not likely 4.6% Not likely 1.0% at all 10.7% at all 4.7% 0 10 20 30 40 50 60 70 80 0 20 40 60 80 100 seek a second opinion regarding an important ask a healthcare worker to explain more fully something they healthcare decision? (statistically significant increase just said that you don't understand? (statistically significant in likelihood, p = 0.0009) increase in likelihood, p = 0.0012) HOW FREQUENTLY DO YOU ENGAGE IN THE FOLLOWING PRACTICES RELATED TO YOUR HEALTHCARE? 48.2% 52.2% Always 46.0% Always 52.2% Always 52.9% 40.6% 12.9% 11.8% Often 7.5% Often 10.8% Often 10.2% 5.7% 17.1% 18.9% Sometimes 12.3% Sometimes 11.8% Sometimes 14.9% 10.2% 20.4% 14.7% 32.1% Never Never 24.0% Never 20.4% 42.1% 0 10 20 30 40 50 60 0 10 20 30 40 50 60 0 10 20 30 40 50 Check that you received the right drug and Call your doctor when you have a medical test Take a written list of all the medications you are strength before leaving the pharmacy. ordered and no one calls you with the results. currently taking when going to the doctor. (not a statistically significant increase in (not a statistically significant increase in (statistically significant increase in likelihood, likelihood, p = 0.7583) likelihood, p = 0.2953) p = 0.0015) IF YOU WERE A PATIENT IN A HOSPITAL, HOW LIKELY ARE YOU TO 75.5% 76.7% 40.7% Very likely Very likely Very likely 67.8% 71.8% 35.0% Likely 14.6% Likely 13.4% Likely 14.7% 17.4% 12.5% 13.5% Somewhat 7.3% Somewhat 6.0% Somewhat 25.0% likely 7.9% likely 6.7% likely 16.0% 2.2% 3.6% 18.5% Not likely Not likely Not likely 34.1% 5.7% 8.4% at all at all at all 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 question the reason for a procedure before question medications or pills if you do not refuse care, such as an x-ray or drawing blood, that you were not told about by your doctor MS14036 it is performed? (statistically significant recognize them and never took this medication increase in likelihood, p = 0.0005) in the past? (statistically significant increase in or nurse? (statistically significant increase in likelihood, p = 0.0100) likelihood, p < 0.0010) Page 26 Pennsylvania Patient Safety Advisory Vol. 11, No. 1—March 2014 ©2014 Pennsylvania Patient Safety Authority Figure 2. Consumer Safety Practices, 2013 and 2006, Ranked by 2013 Percentage of Participants Who Were Positively Inclined PRACTICE 2013 2006 Likely to ask for explanation of 95.5 ±1.7 something you don’t understand 91.0 ±2.0 90.1 ±2.4 Likely to question reason for a procedure 85.2 ±2.3 90.1 ±2.4 Likely to question unfamiliar drugs 84.3 ±2.3 Likely to seek a second opinion regarding 81.5 ±3.1 an important healthcare decision 73.6 ±3.1 63.9 ±3.8 Always/often call for medical test results 63.1 ±3.3 Always/often check drugs 61.1 ±3.9 before leaving the pharmacy 63.0 ±3.3 Likely to ask a healthcare worker to confirm 55.8 ±3.9 your identity before performing a procedure 39.5 ±3.3 55.5 ±4.0 Likely to refuse care not told about 48.5 ±3.4 Always/often take list of 53.5 ±4.0 medications to the physician 46.3 ±3.4 Likely to ask a healthcare worker 42.1 ±3.9 if they have washed their hands 25.9 ±2.9 0 20 40 60 80 100 MS14037 PERCENTAGE Confidence intervals for the proportions were calculated by the Wilson score method without continuity correction. (continued from page 25) of responses between this study and the you to ask a healthcare worker to confirm Penn State polls. your identity before performing a proce- the results of a medical test. Notably, 14 Included among the ranked inclination dure?” improved by 3 positions among there exist differences in population observations, positive inclination of “In the 10 ranked practices, or a difference samples, population locations, and scale regard to your healthcare, how likely are of 16.3%. In a previous article about the Vol. 11, No. 1—March 2014 Pennsylvania Patient Safety Advisory Page 27 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 2006 poll,10 Authority authors noted included study noted that patient fac- consistently divided between commu- low inclination (39.5%) for this practice, tors (e.g., extrovert patient personality, nicating or seeking information from potentially warranting patient and fam- awareness of risk of healthcare-association providers and questioning or challenging ily education. National and Authority infections) were associated with patients providers. There was a noted increase in focus on confirmation of patient identity encouraging providers to wash their the likelihood of Pennsylvania consumer has continued since the 2006 poll. For hands. Because willingness to engage in engagement in consumer patient safety example, improving patient identification the practice remains the lowest of sur- practices, and overall, it appears the has been one of the Joint Commission’s veyed practices in the 2013 poll, focused patient safety movement in Pennsylvania is National Patient Safety Goals (NPSGs) attention to patient engagement in pro- raising awareness of patient safety among since NPSGs were enacted in 2003 and is vider hand hygiene may still be warranted. Pennsylvania healthcare consumers. required by all Joint Commission–accred- In a systematic review published in 2010 As to whether overall attention needs to ited healthcare organizations.15,16 Further, about evidence of patients’ attitudes continue for consumer engagement in patient identification forms a core toward engagement in error prevention, patient safety practices, patient participa- issue of several Authority collaborative as well as the effectiveness of efforts to tion in safety practices may be influenced improvement projects past and present increase patient participation, Schwap- by self-perception and patient-physician (e.g., color-coded wristbands, wrong-site pach notes considerable variation in relationships, among other factors, and surgery, blood specimen mislabeling), as patients’ attitudes about engaging in examination of the reaction of physicians well as featuring among risk reduction “specific, commonly recommended error and healthcare providers to patient and strategies for healthcare providers in the prevention strategies.”18 Behaviors that family engagement may prove beneficial.17 Authority’s Pennsylvania Patient Safety require questioning medical authority Specifics about patient engagement Advisory.3-5 are less likely than behaviors involv- beyond that of questioning provider The 2013 poll participants, similar to 2006 ing “traditional roles,” such as patients behavior may require further study, such participants, remained least inclined toward communicating information to their as on the optimum strategy for implemen- asking about handwashing; however, this healthcare providers. Such division of the tation.17 Similarly, a 2013 viewpoint article consumer practice demonstrated the participants’ responses to the consumer in the Journal of the American Medical second greatest percentage improvement engagement practices was noted in the Association noted that while such engage- in 2013 since the 2006 poll. The medi- 2006 poll results.10 In the 2013 results, ment is unproven, it nevertheless may cal literature abounds with information behaviors that directly challenge actions be valuable to facilitate communication about patients questioning healthcare of healthcare providers do not number between patients and providers, particu- providers about their hand hygiene before among the practices with most inclina- larly physicians.19 Overall, the viewpoint patient treatment. In a systematic review tion, but improvement since the 2006 states, question-like engagement is a start, of patient safety practices, Berger et al. poll is visible nonetheless. and the goal is a more patient-centered addressed interventions encouraging experience in which providers engage in patient engagement in patient safety prac- CONCLUSION open dialogue with patients and minimize tices, including hand hygiene.17 In one “apprehensive silence.” Pennsylvania healthcare consumers were included study addressing hand hygiene, previously reported as being inclined to Acknowledgments 80% to 90% of patients reported willing- engage in practices to promote their own Jonathan R. Treadwell, PhD, associate director, ness to ask providers to wash their hands, Evidence-based Practice Center, ECRI Institute, safety,10 which continued in results of a but only 60% to 70% actually questioned and William Marella, MBA, program director, 2013 poll. Their inclination varied among Pennsylvania Patient Safety Authority, consulted providers, suggesting barriers (e.g., fear of the 10 safety practices but was somewhat on and contributed to statistical testing for this negative reaction by providers). Another article. NOTES 1. Reducing errors in blood specimen label- 2. Shetterly M. Blood specimen labeling 3. Pennsylvania Patient Safety Authority. ing: a multihospital initiative. Pa Patient collaborative: path to results. Pa Patient Preventing wrong-site surgery [online]. Saf Advis [online] 2011 Jun [cited 2014 Saf Advis [online] 2011 Jun [cited 2014 [cited 2014 Jan 15]. http://patientsafety Jan 15]. http://patientsafetyauthority.org/ Jan 15]. http://patientsafetyauthority.org/ authority.org/EducationalTools/Patient ADVISORIES/AdvisoryLibrary/2011/ ADVISORIES/AdvisoryLibrary/2011/ SafetyTools/PWSS/Pages/home.aspx jun8(2)/Pages/47.aspx jun8(2)/Pages/53.aspx Page 28 Pennsylvania Patient Safety Advisory Vol. 11, No. 1—March 2014 ©2014 Pennsylvania Patient Safety Authority 4. Pennsylvania Patient Safety Authority. 9. Agency for Healthcare Research and 15. ECRI Institute. Patient identification. The color of safety [online]. [cited 2014 Quality. Questions to ask your doctor: Healthc Risk Control 2007 Nov;Suppl A: Jan 15]. http://patientsafetyauthority.org/ questions are the answer [online]. 2012 Risk and quality management strategies 16. EducationalTools/PatientSafetyTools/ Sep [cited 2014 Jan 15]. http://www.ahrq. 16. Joint Commission. 2014 National wristbands/Pages/wristband_manual.aspx gov/patients-consumers/patient-involve Patient Safety Goals slide presenta- 5. Use of color-coded patient wristbands ment/ask-your-doctor/index.html tion [online]. 2014 Jan 3 [cited 2014 creates unnecessary risk. PA PSRS Patient 10. Marella W, Finley E, Thomas AD, et al. Jan 15]. http://www.jointcommission. Saf Advis [online] 2005 Dec [cited 2014 Health care consumers’ inclination to org/2014_national_patient_safety_goals_ Jan 15]. http://patientsafetyauthority. engage in selected patient safety practices: slide_presentation org/ADVISORIES/AdvisoryLibrary/ a survey of adults in Pennsylvania. J 17. Berger Z, Flickinger TE, Pfoh E, et al. 2005/dec14_2(suppl2)/Pages/dec14;2 Patient Saf 2007 Dec;3(4):184-9. Promoting engagement by patients and (suppl2).aspx 11. Center for Survey Research Penn State families to reduce adverse events in 6. Pennsylvania Patient Safety Authority. Harrisburg. Spring 2013 Penn State poll: acute care settings: a systematic review 2012 annual report [online]. 2013 Apr 31 report of methods and findings. Harrisburg [online]. BMJ Qual Saf 2013 Dec 13 [cited 2014 Jan 15]. http://patientsafety (PA): Penn State Harrisburg; 2013 May. [cited 2013 Dec 16; epub ahead of print]. authority.org/PatientSafetyAuthority/ 12. Center for Survey Research Penn State http://qualitysafety.bmj.com/content/ Documents/Annual%20Report%20 Harrisburg. 2006 Penn State poll: technical early/2014/01/16/bmjqs-2012-001769.long 2012%20.pdf report. Harrisburg (PA): Penn State Har- 18. Schwappach DL. Review: engaging 7. Joint Commission. Speak Up initiatives risburg; 2006 Dec. patients as vigilant partners in safety: a [online]. [cited 2014 Jan 15]. http://www. 13. Newcombe RG. Two-sided confidence systematic review. Med Care Res Rev 2010 jointcommission.org/speakup.aspx intervals for the single proportion: com- Apr;67(2):119-48. 8. National Patient Safety Foundation. Ask parison of seven methods. Stat Med 1998 19. Judson TJ, Detsky AS, Press MJ. Encour- Me 3 [online]. 2014 [cited 2014 Jan 28]. Apr 30;17(8):857-72. aging patients to ask questions: how to http://www.npsf.org/for-healthcare- 14. Davis RE, Sevdalis N, Vincent CA. overcome “white-coat silence.” JAMA professionals/programs/ask-me-3 Patient involvement in patient safety: how 2013 Jun 12;309(22):2325-6. willing are patients to participate? BMJ Qual Saf 2011 Jan;20(1):108-14. Vol. 11, No. 1—March 2014 Pennsylvania Patient Safety Advisory Page 29 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 1—March 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 by the Pennsylvania Patient Safety Authority. 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Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. 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