Introduction
Are Medicare beneficiaries able to play an active role in preventing medical errors? In response to the Institute of Medicine's report documenting the prevalence of medical errors, the Federal Government has begun to develop messages to encourage patients to take an active role in reducing medical errors. Much of this work has been spearheaded by the Agency for Healthcare Research and Quality (AHRQ), which has developed 20 Tips to Prevent Medical Errors. The Centers for Medicare & Medicaid Services (CMS) is also interested in promoting behaviors to prevent medical errors among its 40 million beneficiaries. As such, CMS conducted research to assess older adults' thoughts about preventing medical errors and to test their responses to existing messages.
Study Objectives
The objectives of the research were twofold, to identify the:
Individual messages on error prevention that resonated most with beneficiaries.
Types of patient-provider relationships that beneficiaries prefer.
Participants
Findings were based on the results from eight 2-hour focus groups, which took place in May 2000 in Baltimore, Maryland and Richmond, Virginia. Each focus group contained nine Medicare beneficiaries. Participants were evenly divided between males and females; 38 percent were black while 62 percent were white; ages ranged from 65 to 80. In both locations, two of the groups were composed of participants with lower education (high school or less) and two with higher education (some college courses or more).
Procedures
In all eight groups, moderators probed what the term “medical errors” meant to participants; their receptiveness to the concept of interacting with health providers assertively and in self-protection; and the kinds of relationships they valued with health providers. Additionally, in six of the groups, participants were asked to rank 28 messages, packaged as “tips,” about what patients can do to reduce medical errors. Most of the messages were drawn from AHRQ's 20 Tips brochure; the additional eight messages were developed by CMS staff or came from other organizations interested in reducing medical errors. Each of the 28 messages were placed in one of the following subject categories: hospital/surgery issues; prescriptions; and general thematic issues. Participants were asked to rank the tips in terms of how likely they were to act on them. After each category was ranked, the tips ranked the highest and lowest were discussed by the group as a whole. During these discussions, moderators asked the participants why they ranked certain tips high or low, what the tips meant to the participants, and how the participants would implement the action recommended by the tips.
Focus Group Findings
Medical Errors and Their Contexts
Focus group participants were asked: “What comes to mind when you hear the term ‘medical errors’?” Immediately, participants discussed surgical errors that they had heard about in the media (e.g., people having the wrong leg amputated). Discussions also included pharmaceutical and diagnostic errors. Respondents were clearly aware that medical errors could occur around medicines. Usually, the pharmaceutical and diagnostic error discussions lasted longer because many participants recalled personal stories.
High and Low Scoring Tips
Messages that received the highest rankings tended to be those that indicated specific ways for patients to inform their health professionals, and to inform themselves about what their health professionals were doing. In the general thematic category, more specific tips (e.g., “Speak up if you have questions or concerns.”) resonated with participants more than general prescription tips (e.g., “Be an active member of your health care team.”).
Highest ranked messages stressed a keeping your doctor informed theme. Participants also preferred messages advocating actions they could accomplish. The most preferred medicine/prescriptions tips are a good example of the keeping your doctor informed theme (Table 1).
Table 1. Highest Ranked Tips, by Category.
| Medicine/Prescriptions |
| Make sure all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. |
| Make sure your doctor knows about any allergies and adverse reactions you have had to medications. |
| Keep a record of the medicines you take and be sure to tell your doctor about them and any allergies you might have. |
| Hospital/Surgery |
| If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done. |
| Choose a hospital that has a lot of experience in treating your condition. |
| General |
| Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. |
| Speak up if you have questions or concerns. |
| Make sure that all health professionals involved in your care have important health information about you. |
SOURCE: Focus group findings on “Messages to Prevent Medical Errors,” 2000.
The top-scoring hospital and general surgery tips had a related theme of informing yourself. Participants said that, within limits, they want to know what is wrong and how to get better. Many, but not all, said they wanted to know as much as they could about their conditions, although some participants indicated that knowing more “makes you worry.”
The lowest scoring tips were those that were seen as embarrassing or rude (e.g., ask health providers if they washed their hands), or as not necessary (e.g., when a doctor writes a prescription, make sure you can read it).
Summary of Findings
Beneficiaries participating in the focus groups were very familiar with the issue of medical errors and strongly endorsed the importance of acting to reduce errors. In particular, participants supported the importance of being proactive, but not confrontational, in their relationships with health professionals.
Our findings suggest that consumer messages on reducing medical errors would work best if they had the following characteristics:
Advocate a collaborative doctor-patient relationship. Participants were more receptive to messages that called for patients to work with, rather than challenge, health professionals.
Specify action to be taken. Participants preferred directive messages that they readily understood, for example, “Make sure that your doctor knows about any allergies and adverse reactions you have had to medicines.” They did not respond to cliches, such as, “Know that ‘more’ is not always better.”
Clearly indicate mode of implementation. Even if patients are comfortable with the message and convinced of its importance, they need directions on how they should act on it. For example, many liked the message, “If you are having surgery, make sure that you, your doctor, and your surgeon are clear on exactly what will be done.” However, not everyone understood how to achieve that agreement.
Conclusion
The fact that Medicare consumers prefer messages that are directive suggests a need to consider crafting the messages for specific contexts and selecting the appropriate channels for dissemination.
With other Federal agencies and private partners, CMS has already used the findings to help craft the 5 Steps, a short guide telling consumers what they can do to prevent errors. Internet address: http://www.quic.gov. CMS will be using the findings from the research about messages on patient safety to develop a strategy that: (1) creates beneficiary awareness, and (2) focuses on promoting the specific tips for preventing medical errors. CMS is conducting additional research to understand what consumers need to know about patient safety and other quality of care issues and how physicians and other clinicians can help educate consumers about patient safety. CMS is also monitoring parallel research by the Leapfrog Group. Internet address: http://www.leapfroggroup.org.
Data Inquiries
For additional information, you may contact Carol Rubenstein, Centers for Medicare & Medicaid Services, at 410-786-1808, or visit their Web site at cms.hhs.gov/medicare/research/reports.