Nursing Practice  Patient Safety

Patient safety is the prevention of healthcare errors and the elimination or mitigation of patient injury caused by healthcare errors. (National Patient Safety Foundation® Board July 2003). A health care error is defined as an unintended healthcare outcome caused by a defect in the delivery of care to a patient.

Health care errors may be errors of commission (doing the wrong thing), omission (not doing the right thing), or execution (doing the right thing incorrectly). Errors may be made by any member of the health care team, including the consumer in any care setting. It can also happen at any point in the care process including diagnosis, treatment and prevention. It is estimated that between 44,000 and 98,000 patients die each year as a result of health care errors. This number exceeds deaths resulting from motor vehicle accidents, breast cancer and AIDS.  The total costs associated with healthcare errors are estimated to be between $17 billion and $29 billion.
 
Patients and their families suffer as a result of health care errors and it produces a wasteful drain on our limited health care resources.  Errors are grossly underreported in most health care settings owing to cultures that either shame those involved or demand "silence."  It is impossible to correct errors if they are not reported.

Errors that plague our health care systems also erode public trust and lead to undesirable attitudes and behaviors among care providers. Nurses, from all patient care settings, need be actively engaged in conversations and problem solving discussions that address ways to improve the safety of patient care. 

Increased attention has occurred regarding the relationship between patient safety and access to RN care. Most notably is the 2004 publication by the Institute of Medicine (IOM) Report Keeping Patients: Transforming the Work Environment of Nurses. This report describes evidence about how nursing work environments can undermine patient safety and quality.

In addition, the 2004 IOM Report described four domains that need to be addressed in order to promote patient safety as it relates to nursing work. These four domains are:

•Transformational Leadership
•Maximizing Workforce Capability
•Work and Workspace Design to Prevent Errors
•Creating and Sustaining a Culture of Safety

The purpose of the Joint Commission on Accredidation of Health Care Organizations (JCAHO) National Patient Safety Goals is to promote specific improvements in patient safety. The Goals highlight problematic areas in healthcare and describe evidence and expert-based solutions to these problems. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the goals focus on system-wide solutions wherever possible. New National Patient Safety goals were released by the JCAHO in May 2006. The website contains goals for a variety of different practice settings, newsletters, facts, a sample outline of a patient safety plan, a "Do not Use Abbreviation List" and more.

http://www.jointcommission.org/PatientSafety/

The Joint Commission International Center for Patient Safety http://www.jcipatientsafety.org features sections for patients and families, health care professionals, and government and business leaders along with information about patient safety goals, sentinel events and solutions and practice safety practices. An online resource for improving patient safety is available at http://www.jcipatientsafety.org" for health care professionals and the public. This resource has over 500 links to trusted patient safety websites along with tips, tools and resources for addressing patient safety problems. The easy-to-use database is a work in progress as users are encouraged to submit additional safe practices along with suggestions on how to make improvements so that it can become an even more helpful resource. There is also a link to several Patient Safety forums.

Safe Care Wisconsin: Partners for Advancing Health Care Safety(SCW) (http://www.metastar.com) has taken over the work of the Wisconsin Patient Safety Institute. SCW's mission is to facilitate the development of partnerships to promote the safest health care in Wisconsin. SCW is a successor to the Wisconsin Patient Safety Institute. A few of the initiatives underway include:

• 100K Lives Campaign - encourages hospitals to make changes in the areas of deployment of rapid response teams, delivery of evidence-based care for acute myocardial infarction, prevention of adverse drug events, and prevention of ventilator-associated pneumonia. The intent is that these changes prevent 100,000 avoidable deaths.
• Appropriate care Measures - the focus is on determining whether patients received appropriate care for the diagnoses of acute myocardial infarction, heart failure and pneumonia. The intent is to improve overall performance in these areas.
• Systems Improvement and Organization Culture Change - involves the implementation of information technology and adoption of telehealth, computerized physician order entry or bar-code systems.