Patient Safety

In 2000, the US Institute of Medicine published its first report on patient safety, To Err is Human. This report discussed patient safety and set a national agenda for improving patient care and reducing medical errors. One of the recommendations of the report was that professional societies such as the North American Spine Society (NASS) “should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement.”

NASS has already demonstrated a firm commitment to quality patient care for many years through its continuing medical education for health care providers, publications and patient education. NASS has made a further commitment to the promotion of patient safety and the prevention of medical errors. To this end, a Task Force on Patient Safety has been established that is developing programs and products to work toward the improvement of health care safety for all spine patients. As part of its patient safety program, NASS has developed this brochure sharing safety tips and information from NASS, the US Agency for Healthcare Research and Quality (AHRQ) and the Quality Interagency Coordination Task Force (QuIC).

What Are Medical Errors?

Medical errors happen when something that was planned as a part of medical care doesn’t work out or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system:

  • Hospitals
  • Clinics
  • Outpatient Surgery Centers
  • Doctors’ Offices
  • Nursing Homes
  • Pharmacies
  • Patients’ Homes

Errors can involve:

  • Medicine
  • Surgery
  • Diagnosis
  • Equipment
  • Lab reports

They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal. Most errors result from problems created by today’s complex health care system. But errors also happen when doctors and their patients have problems communicating. For example, a recent study supported by the Agency for Healthcare Research and Quality found that doctors often do not do enough to help their patients make informed decisions. Uninvolved and uninformed patients are less likely to accept the doctor’s choice of treatment and less likely to do what they need to do to make the treatment work.

What You Can Do

Be Involved in Your Health Care
The single most important way you can help prevent errors is to be an active member of your health care team.
You have a right to question anyone who is involved with your care. Understand that this is your body and life. You must be an active participant in what happens to it. The goal of all medical treatment is to take the best possible care of you. Your help in achieving this goal is mandatory. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results.


Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicine, and dietary supplements such as vitamins and herbs.
At least once a year, bring all your medicines and supplements with you to your doctor. “Brown bagging” your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up-to-date, which can help you get better quality care.

Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
This can help you avoid getting a medicine that can harm you.

When your doctor writes you a prescription, make sure you can read it.
If you can’t read your doctor’s handwriting, your pharmacist might not be able to either.

Ask for information about your medicine in terms you can understand—both when your medicine is prescribed and when you receive it.

  • What is the medicine for?

  • How am I supposed to take it, and for how long?

  • What side effects are likely? What do I do if they occur?

  • Is this medicine safe to take with other medicines or dietary supplements I am taking?

  • What food, drink or activities should I avoid while taking this medicine?

When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?
A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88 percent of medicine errors involved the wrong drug or the wrong dose. If the medicine looks different than you expected, ask the pharmacist about it.

If you have any questions about the directions on your medicine labels, ask.
Medicine labels can be hard to understand. For example, ask if “four doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours.

Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you’re not sure how to use it.

Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons which often do not hold a true teaspoon of liquid. Special devices like marked syringes help people to measure the right dose. Being told how to use the devices helps even more.

Ask for written information about the side effects your medicine could cause.
If you know what might happen, you will be better prepared if it does—or if something unexpected happens instead. That way, you can report the problem right away and get help before it gets worse. A study found that written information about medicine can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

Hospital Stays

If you have a choice, choose a hospital at which many patients have the procedure or surgery you need.
If you have more than one hospital to choose from, ask your doctor which one has the best care and results for your condition. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.

When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.
This includes learning about your medicines and finding out when you can get back to your regular activities. Also ask about follow-up care. Research shows that at discharge time, doctors think their patients understand more than they really do about what they should or should not do when they go home.


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.
Doing surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that you can help ensure it doesn’t happen to you. Ask your doctor to sign, mark and intraoperatively X-ray your spine surgery site.

Know the site and side of the procedure as well as what is being done. In your presurgical conference, (or when the decision to do surgery is made), look at the X-rays and other images and see the problem areas marked. Mark your patient education diagram site and side to correspond to the other images.

Questions for your doctor(s) can include:

  • Who will take charge of my care while I’m in the hospital?

  • Exactly what will you be doing?

  • How long will it take?

  • What will happen after the surgery?

  • How can I expect to feel during recovery?

Ask about the expected good results and possible bad results of the anticipated procedure. Know that certain circumstances or findings may change the scope of the surgical procedure. Tell the surgeon, anesthesiologist and nurses if you have allergies or have ever had a bad reaction to anesthesia.

Take copies of your patient education diagrams with you to the hospital.
After your doctor has explained your surgery and you fully understand the procedure, sign the operative permit and make sure the diagram site and side are marked correctly. Make at least 5 copies and take them with you. Copies should go to:

  • Your family physician. Does he/she understand and agree with the procedure and will they see you during the hospital stay?

  • Family member or friend who will act as your advocate in the hospital. Explain the procedure to them with the possible results.

  • The nurse in charge of your care. Make sure he/she knows the site and side of surgery.

  • Tape a copy to your bed or IV pole for anyone to reference and take it with you to the surgery.

Other Steps You Can Take

Speak up if you have questions or concerns.
Choose a doctor who you feel comfortable talking to about your health and treatment. Take a relative or friend with you if this will help you ask questions and understand the answers. It’s okay to ask questions and to expect answers you can understand. You have a right to question anyone who is involved with your care.

Make sure that someone such as your personal doctor is in charge of your care.
This is especially important if you have many health problems or are in the hospital.

Make sure that all health professionals involved in your care have important health information about you.
Do not assume that everyone knows everything they need to know.

Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can’t).
Even if you think you don’t need help now, you might need it later.

Know that “more” is not always better.
It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it.

If you have a test, don’t assume that no news is good news.
Ask about the results. Find out when and how you will get the results of tests or procedures. If you do not get them when expected—in person, on the phone or in the mail—don’t assume the results are fine. Call your doctor and ask for them. Ask what the results mean for your care.

Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
For example, treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse on the Internet at: Ask your doctor if your treatment is based on the latest evidence.


To Err is Human. Building a Safer Health System. (Report of the Institute of Medicine Quality of Health Care in America Project.) Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, DC: National Academy Press; 2000.

20 Tips to Help Prevent Medical Errors (patient fact sheet). Rockville, MD: Agency for Healthcare Research and Quality (AHRQ) Publication No. 00-PO38, February 2000. Available on the Internet.

Five Steps to Safer Health Care (patient fact sheet). Rockville, MD: Quality Interagency Coordination Task Force, January 2001. Available on the Internet.


This material is made available by the North American Spine Society for educational purposes only. It is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed; rather it is intended to present an approach, view, statement or opinion of the Patient Safety Task Force which may be helpful. This document should not be construed as including all proper methods of prevention or excluding other acceptable methods reasonably directed to obtaining the same results. The ultimate judgment regarding any specific method is to be made in light of all circumstances presented and the needs and resources particular to the locality or institution. NASS disclaims any and all liability for injury or other damages resulting to any individual and for all claims which may arise out of the use of techniques discussed.
©2001, North American Spine Society