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A 2015 article published by Propublica gives an overview of a patient’s life that was lost due to several missteps in her care. One of the comments by Paul Levy to this story reads, “But those of us involved in quality and safety training for medical students and residents can attest to hundreds of such stories, where trainees witness preventable harm and stonewalling and are told in no uncertain terms to keep their mouths shut or face ramifications in their careers.” This confession is shocking. Since the publication of the “To Err Is Human-Building a Safer Health System,” hospitals across the United States have relentlessly worked to improve the safety of the patients. In 2010, McDonald et al., published the results of their descriptive study responding to patient safety incidents at a large tertiary care center in the United States. In this paper they report that 2 years post implementation of the “Seven Pillars” process, the hospital saw more than 2000 incident reports annually and approximately 100 or more investigations with root cause analysis, which really translates to at least 200 system improvement laying the foundation for 106 disclosure conversations and 20 full disclosures of inappropriate and unreasonable care causing harm to patients.

Impressed with the “Seven Pillars” process, the Agency for Healthcare Research and Quality (AHRQ), selected Medstar Health to develop and pilot the “Communication and Optimal Resolution Online Toolkit (CANDOR).” CANDOR toolkit is vital if we are going to reduce the death due to preventable errors. If we are to improve patient safety, healthcare entities must see patients and families as partners and advisors to improve the safety, failing which we will be just spinning the wheel with no end point. Healthcare organizations must set a goal to form a partnership with patients and families as a top priority to prevent medical errors and increase security. The foundation of a safe healthcare visit is the connection between the patient and medical providers.


In a previous blog, I discussed the introduction of PACs (Patient and Family Advisory Council, Patient Advisory Councils). Many healthcare organizations are introducing PFACs, PACs as a way to increase patient safety as well as build a connection between the patients, their families and medical staff. Patients, support systems (family, friends), primary care providers, and healthcare staff typically comprise PACs. These members aim to improve safety, quality, and the patient experience. PACs may be the answer for increasing patient safety. If you want to develop a PAC for your healthcare organization, follow these tips.


Plan and Timeline

The first step is having leadership that is committed to supporting the staff and patients. To begin a PAC or PFAC, the leadership team should set goals, develop a plan for how to achieve those goals, and set a meeting date. The program must be presented to those in the PAC as well as the organization’s staff. By communicating the plan, you will be able to set expectations for the goals of the PAC or PFAC and welcome input and feedback.


Invite Patients

When the PAC or PFAC is beginning to form, do not be hesitate to invite patients to participate. During the development of a patient advisory council, you must ensure you have the right mix of patients,  providers, and caregivers to create an open and productive atmosphere. When you invite patients, be sure to introduce the PAC approach and a discussion of how the patient will be involved. Furthermore, it is vital that you have a diverse patient and provider population. This will ensure that you have members who can speak to multiple kinds of patient needs.


Hold a Meeting

The first gathering is a significant step in launching and sustaining a PAC. During the first meeting, you should cover expectations and responsibilities of each role, minimize negativity, address trusting the process from patients, providers, and staff, and encourage open and honest discussion. It may take several meetings for patients to become comfortable with speaking up.  A facilitator may also be needed to ensure the group stays on task. Lastly, PAC members should draft their own mission statement and vision, creating something that honors their own values.


Mitra Rangarajan is an expert in the healthcare field and strives to empower patients to take charge of their health and safety. Read more on her patient safety research here!