Patient safety in nursing practice

AORN Journal,  Sept, 2007  by Marybeth Farquhar,  Beth A. Collins Sharp,  Carolyn M. Clancy

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The Institute of Medicine's (IOM's) landmark report To Err is Human: Building a Safer Health System (1) generated a national outcry when it was published in 2000. In many ways, it created momentum for a patient safety transformation that persists today. Seven years later, patient safety is a central public concern, as evidenced by the number of quality reporting and improvement initiatives that have proliferated across the country. We need to continue the momentum of improvement--and we must also recognize that improvement and transformation are a team effort, with each team member bearing significant responsibility.

The IOM defines patient safety as

   freedom from accidental injury;
   ensuring patient safety involves the
   establishment of operational systems
   and processes that minimize the
   likelihood of errors and maximize the
   likelihood of intercepting them when
   they Occur. (1(p211))

In To Err is Human, the IOM estimated that preventable medical errors are responsible for up to 98,000 patient deaths in hospitals every year, with an annual financial cost of up to $29 billion--as well as incalculable emotional costs for patients, their families, and their caregivers. (1)

Nurses, as the largest group of health care providers in the nation offering direct patient care, are vital to the effort to prevent errors. Nurses have a significant role in improving care; because of their broad yet intimate perspective, nurses are an indispensable part of the endeavor to find innovative solutions to improve safety.

The Agency for Healthcare Research and Quality (AHRQ) is a partner in this journey. The AHRQ's mission, "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans," (2) reflects the need to fund research--and more. We need to make sure that the findings, knowledge, and tools that result from research are broadly applied to improve health and health care.

AHRQ RESEARCH

For instance, AHRQ-funded research last year demonstrated that patients with heart failure whose care was directed by nurse managers could perform everyday activities better and had fewer hospitalizations than patients who self-managed their care. (3) In addition, an evidence report prepared for the AHRQ by the Minnesota Evidence-based Practice Center in March 2007 demonstrated that in-creased nursing staffing in hospitals was associated with lower hospital-related mortality, fewer incidences of failure to rescue, and other positive patient outcomes, although the association is not necessarily causal. (4)

Soon, we will get input from another critical source: patients themselves. The Consumer Assessment of Healthcare Providers and Systems Hospital Survey (ie, H-CAHPS), which provides a standardized instrument and data collection methodology for measuring patients' perspectives on hospital care, was developed by the AHRQ in partnership with the Centers for Medicare & Medicaid Services to gauge how patients perceive the quality of their own hospital treatment. (5) Among other things, the survey results will tell us how well nurses are communicating with patients and how this affects patients' overall perception of care.

APPLYING THE KNOWLEDGE

We must continue working to apply the knowledge gained from our research to clinical practice. For the momentum of change to continue, all stakeholders must be on board, (6) from researchers and caregivers to educators and policy makers. To transform our health care system, it also is essential to have the support of leaders and managers at all levels in a variety of organizations.

Chief among the factors that will lead to system transformation is our knowledge that patient safety problems are usually the result of structural design flaws. The "blame and shame" approach merely drives problems underground. Instead, we need a systems approach to seek solutions in the physical and cultural environment. For example, health care procedures, organizational knowledge transfer, technical failures, inadequate policies and procedures, the way that nursing units are arranged, communication among health care teams, and staffing issues are all significant factors that may dramatically affect the individual caregiver's ability to deliver safe, high-quality care. These issues, left unaddressed, may result in additional errors. (6)

One related, serious issue that we face is the long hours demanded of nurses and other health care providers. This poses a threat to patient safety because caregivers who have worked long hours display slower reaction time, decreased energy, and reduced attention to detail. (7) Research by the AHRQ is confirming that we must seek solutions with regard to long hours; one AHRQ-funded study found that nurses who worked shifts longer than 12 hours or who worked unplanned overtime were three times more likely than other nurses to make errors such as giving patients

incorrect medications or dosages or administering medications late. (8) Another study showed that the odds of an error occurring were twice as high among nurses who rotated shifts as among nurses working straight days or evenings. (9)