There has been significant interest internationally in involving patients in efforts to improve patient safety. In this issue of the journal, Melinda Lyons uses the principles of safety engineering and insights from human reliability analyses to argue that relying on patients to check on the delivery of their health care would be ineffective as a general strategy for promoting patient safety (see page 140).¹ Lyons also notes that such reliance would burden patients with responsibilities that many would be unable to fulfil.

The claim that relying on patients to check on the care they receive from health professionals is neither an effective nor an appropriate strategy for promoting patient safety has several implications. One obvious inference is that those seeking to improve patient safety should be investing in other strategies. However, the claim need not lead us to conclude that all attempts to support patient involvement in efforts to promote patient safety are misguided. There are important differences between relying on patients to check on the delivery of their health care to ensure their safety and involving patients in their care while efforts are made to improve their safety. Some forms of patient involvement might be justified for reasons other than their potential to improve patient safety. They need not burden patients beyond their ability. Lyons’ paper should prompt us to think carefully about the various forms that patient involvement might take and why they might be important.

Patients may be involved in health care—including safety-oriented activities—in a variety of ways, both as individuals and as patient representatives in collective efforts to improve health care more generally. I focus here on the former.

Patients’ involvement in their own health care is partly a function of what patients do in relation to their health care and in interactions with health professionals. It is also a function of what health professionals do in relation to them and how both parties think and feel about their own and each others’ roles, efforts and contributions. A person may feel involved even if their contribution is not evident to others, and this might be an important aspect of involvement.²

Patients’ involvement in safety-oriented activities might be valued for reasons other than its impact on patient safety. For example, hospitals should now have a number of strategies in place to ensure that drugs are given as intended to the people for whom they were prescribed. Health professionals who administer drugs in hospitals might enable patients to be involved in the final check that takes place at the point of care simply by communicating clearly and courteously during the process—perhaps something along the lines of:


 Now Mrs Smith, Jane, we’ve got three tablets here, and I’m double checking that they are the ones the doctor has prescribed in your chart to treat the H pylori infection that caused your ulcer. There’s amoxicillin and clarithromycin – they’re the two antibiotics, and this is the omeprazole, which helps reduce the acidity. OK?

If this is said in a kindly conversational manner, it might have several advantages, including:

• Communicating respect for the patient as a person who should be given a say before anything is done to them³

• Serving as a form of patient education, facilitating or reinforcing patients’ understanding of what drugs they are being given and why. (This may be particularly important for patients who will subsequently be expected to self-medicate at home)

• Providing patients with a comfortable opportunity to query what they are being given or ask questions about their treatment without appearing to be confrontational (what the clinician says should give the patient an easy conversational entry point)

• Enabling the patient to see that checks are being carried out and that there is scope for them to speak up if they do have any concerns.

These advantages might be achieved without health professionals abdicating their own responsibility for ensuring correct administration of drugs and without giving patients the impression that they need to take on a potentially burdensome independent checking role.

A second example relates to efforts to ensure correct site surgery. Safety protocols that require surgeons to visit patients preoperatively and mark the operative site before the patient is sedated or anaesthetised might encourage patients to be involved in checking with their healthcare providers (as opposed to checking up on them).⁴ Depending on what the surgeon says, these protocols might have advantages similar to those outlined above—especially if patients are told in advance what the surgeon will do and why. See for example the information produced for patients by the National Patient Safety Agency in England⁵ and the US Department of Veterans Affairs National Center for Patient Safety.⁶

Of course, efforts to promote patient involvement in their safety might have disadvantages as well as advantages. The evidence is currently lacking, but concerns have been raised about the potential impact of some interventions on a number of important domains.⁷ The acceptability of particular interventions is likely to vary significantly between countries and healthcare systems that have different norms for patients’ and professionals’ roles. The effects of interventions will differ according to the context in which they are introduced. Rigorous evaluations are now needed to put the debates about just what is appropriate onto a firmer footing.

Some kinds of effort to promote or enable patient involvement are likely to be appropriate, however. Trustworthy healthcare providers who genuinely have patients’ best health interests at heart will support and enable patients and their family members to do what they can to contribute to their own safety—or at least will not hinder their efforts.⁴ But even to avoid hindering the reasonable efforts of patients and family members to ensure their safety as they use health services, healthcare providers may need to work positively to improve support for at least some forms of involvement. Just as efforts are currently needed to ensure that medical students feel able to speak up if they see things that cause them to be concerned for a patient’s safety, and that they will be listened to if they do,⁸ so efforts may be needed to ensure that patients and their family members are similarly enabled and listened to. Broad initiatives to make health care more patient or family centred may facilitate this, but more specific interventions may also be needed.

Lyons’ paper presents a strong case against reliance on checking by patients as a means of promoting healthcare safety. However, support for some interventions to promote patient involvement, including, in particular, in safety-oriented activities, may be justified—and perhaps even ethically required. These interventions may fulfil key communicative and educational purposes. They may express healthcare providers’ respect for patients as people, their commitment to ensure patients’ safety, and their willingness to enable people to help themselves and their families as they use health services.