When Patients Speak Up, Hospitals Get Safer
Patients and families can play a vital role in preventing medical errors. Learn how speaking up saves lives on World Patient Safety Day.
In March 2021 - during the height of the pandemic when family members were still being turned away from hospital rooms, and nurses were trading shifts like a relay team handing off the baton at full stride - an “Ask the Expert” conversation unfolded on Smart Patients about a subject that rarely makes headlines until it breaks hearts: patient safety. Specifically, about that moment when ordinary people, armed with nothing more than a pen and the courage to speak up, become the last line of defense against medical errors, a leading cause of preventable death.
The guests were Sorrel King, who became a nationally-known advocate after her 18-month-old daughter Josie died from medical errors; and Marty Hatlie, a longtime leader in quality and safety improvement. What emerged from the discussion was both sobering and surprisingly hopeful about how the simple act of paying attention, taking notes, and asking questions can literally save lives.
Transparency is a Treatment
But there's something else happening here, something bigger than just catching errors. We're living in an unprecedented time in who gets to see what's written about them. As of April 2021, "blocking" patients from their own health records in the United States is against the law and may result in fines for hospitals and clinicians. Thanks to the 21st Century Cures Act, patients now have full access to their medical records – not just test results, but the actual notes doctors write about them. Everything that’s on record about their case!
“I have been living and breathing patient safety for more than 20 years,” Ms. King said. “Hospitals are constantly striving to deliver safer, more patient- and family-centered care, and that is a good thing for all of us.” Her message was clear: trust the people caring for you, show gratitude, then speak up anyway.
Patient safety is both a science and a culture. It is rooted in data, measurement, and system redesign; and because safety ultimately lives in people, it depends on shared norms. There needs to be psychological safety to speak up, listening across all levels, learning from near-misses, and welcoming patients as teammates to maximize the effectiveness of policies and checklists.
This observation from Mr. Hatlie sparked a stream of practical advice: “We can all be part of making the health system safer. I’m especially interested in how patients and their family caregivers find ways to give feedback to providers about risks you see—things you see that perhaps your providers don’t.”
In response, one caregiver described keeping a running log at her husband’s bedside during a cancer hospitalization. The notes, she said, did something subtle but powerful: they conferred authority.
“For some reason having things written down adds to the authority of the patient or family member,” she said. In a single day, those notes headed off two errors. One was a sedating medication a physician had already discontinued. "I told the nurse it had been discontinued. She checked and came back: I was correct." The second was an antibiotic nearly getting cut off too early. Again the caregiver's note was confirmed by the patient's official record, and the antibiotic was continued.
Later, when a tech arrived to prepare for a PICC-line insertion and warned that nothing should be injected into the left arm beforehand, she stood watch “like a guard dog” until the line was safely in. “I feel for the many solitary patients who are not functioning well enough to take notes,” she added.
Time to Think Is Part of the Care
Medication mistakes, whether it’s the wrong drug, wrong dose, or wrong schedule, came up repeatedly. One member found an incorrect prescription posted to her patient portal and had to apply “continued pressure” to be heard.
Others had fears about raising concerns that would brand them as difficult. However, the experts noted that hospitals now live or die by patient-experience scores, and most employ patient-advocacy staff who can investigate grievances and act as neutral go-betweens with clinicians. “A good way to start is by calling and asking to talk to the patient advocate,” Mr. Hatlie said. “They are trained to listen, investigate, and resolve problems.”
The group also discussed how safety is not only about catching errors; it is also about consent that truly informs. They dove into how often “informed consent” functions as a liability shield rather than a decision aid.
Mr. Hatlie cited a patient advocacy checklist that people can carry into any procedure discussion: Are there alternatives—including doing nothing? Is the drug off-label or under a black-box warning? Who exactly will perform the procedure, and how experienced are they? What are the out-of-pocket costs? What does recovery look like, infection risks included?
Most patients, he added, want time to think “a full day before signing anything for non-emergencies” and the option to review their own notes.
Weaving the Safety Net
Amid the policy talk, the conversation kept returning to the loneliness of patients who lack an advocate. One participant who had prevented “several possibly serious errors” during a lengthy hospital stay worried aloud about those who cannot take notes or keep vigil. Ms. King and Mr. Hatlie pointed to concrete workarounds: recruit a circle of coworkers or community members to rotate short “safety shifts,” especially over the nursing shift changes; consider hiring a professional patient navigator; tap local resources through organizations like AARP or area agencies on aging. For families living far away, they shared a guide to engaging from afar which included what to ask, when to call, and how to join decision-making even if you can’t be at the bedside.
Health-technology frustrations surfaced too. Electronic records were celebrated for solving illegible handwriting and condemned for creating new hazards such as misclicks, "autopopulated" errors, and labyrinthine portals that bury what matters. Patients compared notes on getting inaccurate labs removed (“they added a correction but wouldn’t expunge the wrong values”) and on the slow choreography of interoperability that still forces many to hand-carry records between systems.
“My view is that it’s my job to make sure all the info gets from provider to provider,” one participant said with weary pragmatism. “It shouldn’t be; but if nobody else is getting it done, it is.”
The experts encouraged the participants to report not just “harms” but “no-harm events,” near misses, and unsafe conditions. A spilled infusion bag after a pump slipped from its bracket? Report it today, and again in six months if nothing in the procedure changes. A policy that routes cancer patients to higher-dose CT scanners simply because “that’s the way it’s done?” Report that, too. “Tracking patient safety events is one of the field’s most frustrating challenges,” Mr. Hatlie said. “Under-reporting by staff increases the importance of reporting by patients.” He urged hospitals to adopt “Condition H” (H for “Help”), a program championed by the Josie King Foundation that empowers patients or families to call a rapid-response team directly if they see trouble brewing.
Safety is a Team Sport
If there was a single theme, it was that safety is a team sport—and the team is bigger than a ward roster. It includes the patient who pauses an injection to ask, “What is that medication called?”... the spouse who says, “I think the doctor stopped that drug at 10 a.m.—could you check?”... the daughter who records a clinic visit (with permission) and on replay finds she hears what fear made her miss in the moment. It includes the grateful note to a nurse after a hard shift, the second call to the patient-experience office when the first goes nowhere, the neighbor who takes a two-hour turn at the bedside because nighttime is when mistakes like to hide.
The woman who kept meticulous notes at her husband's bedside and caught two potentially dangerous medication errors in a single day. The patient who questioned an incorrect prescription in her portal and kept pushing until someone listened. The countless family members who've learned to speak up, to ask for names, to stay alert during shift changes when mistakes like to hide.
“We have come a long way but there is still work to be done,” Ms. King said, as an invitation rather than a lament. Safety is a practice that hospitals renew—shift by shift, chart by chart, question by question—with patients and families as full participants.
World Patient Safety Day is September 17.
To be part of the team, it just takes ordinary courage, bringing a notebook, asking the names of the people caring for you, thanking them, and then asking your next question. And if something doesn’t look right, say so kindly at first, more insistently if you must. In the language of safety science, that’s called a “good catch.” In the language of the families who have learned how much it matters, it’s called love.