In 2000, the Institute of Medicine (IOM) stated in its To Err is Human: Building a Safer Health Care System publication that between 44,000 and 98,000 patient deaths result each year from preventable errors in acute care hospitals. The report identified several factors that contribute to these findings and motivated other national bodies to examine ways they could improve patient safety and quality care. One of these groups, The Joint Commission (TJC), requires that health care organizations create a culture of safety and encourage patients and families to become safety partners in protecting patients from harm.

The Joint Commission is a national organization that offers peer evaluation for accreditation every 3 years for all types of U.S. health care agencies that meet their standards. Although acute care hospitals are accredited more often than other types of settings, many home care agencies, nursing homes, and ambulatory care centers are also TJC-accredited. Some agencies chose accreditation by other organizations other than TJC, but safety is a major focus for all of them.

In 2002, TJC published its first annual National Patient Safety Goals (NPSGs). These Goals require health care organizations to focus on specific priority safety practices, many of which involve nursing care. Since that time, TJC continues to add new Goals each year. NPSGs address high-risk issues such as drug administration, fall reduction, pressure ulcer prevention, and communication among health care team members. When appropriate, this textbook discusses related NPSGs. A complete list of these goals can be found on TJC website at www.jointcommission.org.

Protecting Five Million Lives from Harm

As a result of the IOM report and other data from national studies, the Institute for Healthcare Improvement (IHI) estimates that there are nearly 15 million health care errors in U.S. hospitals each year, or 40,000 per day (IHI, 2005). In 2004, the IHI and its partner health care organizations launched the 100,000 Lives Campaign—an effort to save patient lives over an 18-month targeted time frame. Six interventions for quality improvement changes in care were implemented by partnering health care agencies (Table 1-1). As a result of this project, an estimated 122,000 patient lives were saved!

TABLE 1-1 IHI INTERVENTIONS TO SAVE PATIENT LIVES AND PREVENT PATIENT HARM

INTERVENTIONS TO SAVE PATIENT LIVES	INTERVENTIONS TO PREVENT PATIENT HARM
Deploy Rapid Response Teams.	Prevent harm from High-Alert Drugs (e.g., anticoagulants, insulin, opioids).
Provide reliable, evidence-based care for acute myocardial infarction.	Reduce surgical complications.
Prevent central line infections.	Prevent pressure ulcers.
Prevent adverse drug events (ADEs).	Reduce methicillin-resistant Staphylococcus aureus (MRSA) infections.
Prevent surgical site infections (SSIs).	Provide reliable, evidence-based care for congestive heart failure.
Prevent ventilator-associated pneumonia (VAP).	Get boards of health care organizations to support measures to promote safe patient care.

IHI, Institute for Healthcare Improvement.

The next IHI objective was to protect patients from five million incidents of medical harm over a 2-year period (December 2006-December 2008) (IHI, 2005). Medical harm refers not just to physician incidents but to errors caused by all members of the health care team or system that lead to patient injury or death. To meet this IHI objective, six interventions for changes in care were added to the original list. As seen in Table 1-1, many of these interventions are within the scope of nursing practice and are therefore emphasized throughout this textbook. Some interventions, such as pressure ulcer prevention and adverse drug event reduction, are also part of TJC’s National Patient Safety Goals.

One of the most successful IHI initiatives was the creation of the Rapid Response Team (RRT), also called the Medical Emergency Team (MET). Rapid Response Teams save lives and decrease the risk for harm by providing care to patients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team who responds to patient arrests, it intervenes rapidly when needed for those who are beginning to clinically decline.

Nursing Safety Priority

Critical Rescue

Early clinical changes in condition occur in most patients for up to 48 hours before a “Code Blue.” Therefore observe for, document, and communicate early indicators of patient decline, including decreasing blood pressure, increasing heart rate, and changes in mental status.

Members of an RRT are critical care experts who are on-site and available at any time. Although membership varies among facilities, the team may consist of an ICU nurse, respiratory therapist, intensivist (physician who specializes in critical care), and/or hospitalist (family practitioner or internist employed by the hospital). In other hospitals, acute care nurse practitioners or medical residents may be part of the team. The team responds to emergency calls, usually from nurses, according to established agency protocols and policies. Patient families may also activate the RRT (Bogert et al., 2010). Outcome data demonstrate that the RRT approach to emergency care reduces medical complications and decreases the number of cardiac and respiratory arrests.

TJC’s National Patient Safety Goals also include the need for early intervention for patients who are clinically changing. They require each health care organization to establish criteria for patients, families, or staff to call for additional assistance in response to an actual or perceived change in the patient’s condition.

Institute of Medicine/Quality and Safety Education for Nurses Core Competencies

The Institute of Medicine (IOM) published many reports during the past 15 years suggesting ways to improve patient safety and quality care. One of its reports, Health Professions Education: A Bridge to Quality, identified five broad core competencies for health care professionals to ensure patient safety and quality care (IOM, 2003). All of these competencies are interrelated and include:

• Provide patient-centered care.

• Collaborate with the interdisciplinary health care team.

• Implement evidence-based practice.

• Use quality improvement in patient care.

• Use informatics in patient care.

Several years later, the Quality and Safety Education for Nurses (QSEN) initiative validated the IOM competencies for nursing practice and added safety as a separate competency to emphasize its importance. In addition, the QSEN project team created specific knowledge, skills, and attitudes (KSAs) needed to develop each core competency, using a Delphi research approach.

This text highlights the QSEN competencies in its Decision-Making Challenges. Teaching/learning activities to help students develop specific KSAs can be found in the Instructor Resources (IR) on the Evolve website and accompanying Student Study Guide. Each QSEN competency is briefly described in the following six sections.

Patient-Centered Care

To be competent in patient-centered care, the medical-surgical nurse recognizes “the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for [the] patient’s preferences, values, and needs” (Quality and Safety Education for Nurses [QSEN], 2011). The KSAs for competence in patient-centered care focus on communication, compassion, culture, patient education and empowerment, and respect for patients and their families (Table 1-2).

TABLE 1-2 EXAMPLES OF KNOWLEDGE, SKILLS, AND ATTITUDES NEEDED TO DEVELOP THE IOM/QSEN PATIENT-CENTERED CARE COMPETENCY

KNOWLEDGE	SKILLS	ATTITUDES
Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.	Provide patient-centered care with sensitivity and respect for the diversity of human experience.	Recognize personally held attitudes about working with different ethnic, cultural, and social backgrounds.
Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort.	Assess presence and extent of pain and suffering.	Recognize personally held values and beliefs about the management of pain and suffering.
Examine how the safety, quality, and cost-effectiveness of health care can be improved through the active involvement of patients and families.	Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management.	Respect patient preferences for degree of active engagement in care processes.
Explore ethical and legal implications of patient-centered care.	Facilitate informed patient consent for care.	Respect and encourage individual expression of patient values, preferences, and expressed needs.