Safety in hospitals is often centered on patients — but it is equally important to consider the risks faced by others, like visitors. To identify and correct blind spots, it is critical that hospitals report all injuries that occur on site, even those that do not involve patients.
Patient safety reports can and should include harm to anyone in the care environment, including visitors. Courts in several jurisdictions have recognized that visitor-related incidents may qualify as patient safety work product (PSWP), reinforcing their importance in safety learning. Importantly, a visitor does not need to become a patient for their event to be reportable as PSWP.
Case Study
At one hospital, an elderly husband was accompanying his wife to a clinic appointment and stepped away to find the restroom. The hallway lights were dim, and the floor had just been mopped. There were no warning signs. He slipped, fell, and injured his ribs.
What followed was a cascade: X-rays were taken, and he was told it would take a week for results. No follow-up contact occurred.
Two weeks later, still in pain and struggling to breathe, he returned to the clinic. He was diagnosed with GERD and prescribed additional pain medication.
Eight days later, he messaged his provider — barely able to speak — asking whether he should return to the clinic or go to urgent care. The following day, he was advised to seek immediate care. At urgent care, he was sent to the emergency department, where he was admitted with multiple rib fractures and a collapsed lung — injuries stemming from the original fall.
This case illustrates the real risk of missed or delayed diagnosis, as well as the critical oversight of visitor safety. While this incident was reported internally, cases like these are not always submitted to patient safety organizations — depriving other hospitals the opportunity of shared learning. Hospitals should review their safety plans with an eye toward potential blind spots, because providing safe patient care depends on protecting all who walk through hospitals’ doors.
