Patient Safety

In any discipline, most practitioners think of a leader as someone with positional authority. Terms such as manager, director, chief, and leader convey positional authority. In healthcare organizations, a hierarchy exists of “who is in charge.” Realistically, however, every registered nurse is seen by law as a leader—one who has the opportunity and authority to make changes for his or her patients. Even as far back as Florence Nightingale’s era, patient safety was important. She focused on changing the way health care was delivered to make a difference in the outcomes of care for those who served in the Crimean War. Yet, in the United States, it was not until the end of the twentieth century that major efforts refocused on the basic safety and quality outcomes of care for patients. This shift to being consumed with a passion for patient safety is a hallmark of today’s healthcare delivery and the target for the care of tomorrow. This chapter provides an overview of the key thoughts about patient safety as the basis for all aspects of leading and managing in nursing. Patient safety, and subsequently quality of care, is why the public entrusts us with licensure and why we use our passion for caring.

Objectives

• Identify the key organizations leading patient safety movements in the United States.

• Value the need for a focus on patient safety.

• Apply the concepts of today’s expectations for how patient safety is implemented.

Terms to Know

Agency for Healthcare Research and Quality (AHRQ)

DNV (Det Norske Veritas)

Institute for Healthcare Improvement (IHI)

Institute of Medicine (IOM)

Magnet Recognition Program^®

National Quality Forum (NQF)

The Joint Commission

The Challenge

Vickie S. Simpson BA, BSN, RN, CCRN, CPN Dell Children’s Medical Center of Central Texas, Austin, Texas

Over the years, our hospital has focused on pressure ulcers. In 2002, for example, we reviewed literature on pediatric pressure ulcer risk assessment scales and prevention interventions. A couple of years later, as we were doing our pediatric pressure ulcer risk policy, we realized that pressure ulcers were not tracked. So it was impossible to determine the true incidence. Thus we instituted a tracking system. We also developed a pediatric SKIN bundle. SKIN stands for Surface selection, Keep turning, Incontinence management, and Nutrition.

Many of these efforts included broad interdisciplinary teams. For example, after moving to our new facility in 2007, we noticed a trend of pressure ulcer development in nasally intubated patients. When a root cause analysis was completed with members of the anesthesia and respiratory therapy departments, staff in the critical care unit, and the cardiovascular surgeon, numerous issues were identified. These issues included not purchasing arms for the new ventilators and identification of the need for a different taping process for nasally intubated children, which was developed by our respiratory therapists. Our outcome is that now we have no pressure ulcers on nasally intubated children in our facility.

In 2009, we identified a new trend in our patient population. It was including more overweight teenagers. We had to decide what to do.

What do you think you would do if you were this nurse?

Introduction

In Chapter 1, the concepts of leading and managing were presented. The question is, however, leading for what? No issue is more prominent in the literature or in healthcare organizations than the concern for patient safety. Although many other aspects of health care are discussed, they all center on patient safety. Many factors and individuals have influenced the nursing profession’s and the public’s concern about patient safety, but the seminal work was To Err is Human: Building a Safer Health System (2000), produced by the Institute of Medicine (IOM). From that report through the 2005 publication, Preventing Medication Errors, the IOM focused its work on multiple issues surrounding patient safety. Even more popularized publications, such as How Doctors Think (Groopman, 2007) and The Best Practice: How the New Quality Movement is Transforming Medicine (Kenney, 2008), show how important the basic building block of quality—patient safety—is. This focus fits well with the basic patient advocacy role that nurses have supported over decades.

Because the core of concern in any healthcare organization is safety, it also is the core for leaders and managers in nursing. Safety, and subsequently quality, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change, and information technology and delegation decisions. Most professionals would agree that three major driving forces are behind the current emphasis on quality: IOM, the Agency for Healthcare Research and Quality (AHRQ), and The National Quality Forum (NQF). Also, other groups such as The Joint Commission, the new accrediting organization (the Det Norske Veritas [DNV]), and the Magnet Recognition Program® have incorporated specific standards and expectations about safety and quality into their respective work. No nurse can function today without a focus on patient safety, nor can any nurse leader or manager.

The Institute of Medicine Reports on Quality

Although many reports about quality and safety had been issued before 2000, To Err is Human is the report credited with causing sufficient alarm about how widespread the issue of patient safety concerns was. When the number of deaths (98,000 annually) attributable to medical error was announced, the interest in safety intensified. Suddenly this issue was not related to just a few isolated instances nor was it likely to diminish without some concerted action. Probably the hallmark of this publication was the acknowledgment that errors commonly occurred because of system errors rather than individual practitioner incompetence. This insight, that it was the system and not the practitioners that needed to be addressed, placed even more emphasis on roles such as chief medical officers and chief nursing officers. Hospital boards that once focused almost exclusively on finances suddenly wanted more of their agendas devoted to discussions about quality and patient safety. The call for a comprehensive approach to the issue of improving patient safety really spurred the release of a second IOM report.

This next report, Crossing the Quality Chasm, was released the subsequent year (IOM, 2001). The intent of this second book was to improve the systems within which health care was delivered; after all, the first report identified that systems rather than incompetent people were the major concern. The report spelled out six major aims in providing health care, as shown in Box 2-1.

BOX 2-1

The Aims of Providing Health Care

From Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

These aims were designed to enhance the quality of care that was delivered. Most are well documented in the literature, and two of them seem to be receiving much attention. One, patient-centered care, has lessened the past practices of disciplines (e.g., nursing and pharmacy) and services (e.g., orthopedics and urology) vying for control of the patient. Now, because care is to be rendered with the patient rather than to the patient, the emphasis of care is about what is provided—not who controls the decision about care. The second aim, equitable, has emphasized what the literature refers to as disparities and has led to thoughtful consideration of what best practices are and how they can be provided to the masses.

The report went on to acknowledge elements of care that nurses commonly value. For example, the report cited the idea of a healing environment, individualized care, autonomy of the patient in making decisions, evidence-based decision making, and the need for transparency. Although those elements of a healthcare delivery system might not seem so dramatic today, they were fairly revolutionary in 2001. This report also provided substantive support for the use of information technology within health care. In addition, it provided the impetus for payment methods being based on quality outcomes and addressed the issue of preparing the future workforce. This latter recommendation formed the basis for another IOM report, Health Professions Education: A Bridge to Quality (IOM, 2003).

Unlike the earlier reports, the Health Professions Education report emerged as the work of an invitational summit. In this report, one of the major concerns about safety was exposed publicly, namely that we educate disciplines in silos and then expect them to function as an integrated whole. This is true of both basic and continuing professional education. The report stated, “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (IOM, 2003, p. 3). Box 2-2 emphasizes those five competencies about health professional education.

BOX 2-2

Competencies of Health Professionals

• Provide patient-centered care

• Work in interdisciplinary teams

• Employ evidence-based practice

• Apply quality improvement

• Utilize informatics

From Institute of Medicine (IOM). (2003). Health professions education: A bridge to quality. Washington, DC: National Academy Press.

The idea of this report was to shrink the chasm between learning and reality so that learning was enhanced and reality was more closely aligned with that learning. A commitment to this redirection of learning is critical for “learning organizations,” a term coined by Peter Senge. Thus constant learning is a commitment every healthcare professional must have. Although it is the individual’s accountability to maintain competence and participate in learning, the organization can hinder or enhance that individual’s need to meet this expectation. Learning organizations exhibit a positive commitment to enhance people’s learning and changing.

After looking at safety, the system and core competencies of health professionals, the IOM turned its attention to the workplace itself. As a result, many nurses think of the IOM report Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2004) as the major impetus behind many changes that improved the working conditions for nurses. Because nurses are so inextricably linked with patients, it was logical that the importance of the role of nurses in health care emerged as an area of focus. This report identified that nurses had lost trust in the organizations in which they worked and that “flattening” the organization resulted in fewer clinical leaders being available to advocate for staff and patients and to provide resources to those delivering direct care. Further, numerous sources of unsafe equipment, supplies, and practices were discussed. Finally, so many organizations were still engaged in punitive practices related to errors rather than redirecting attention to the broader view of the system.

This report focused on direct-care nurses being able to participate in decisions that affected them and their provision of care, which helped reinforce the ongoing work of shared governance. Addressing staffing issues was accomplished on a broad scale. In other words, the broad processes for determining staffing requirements and how to address those were identified. Average hours per patient day of care, staffing levels, turnover rates, public reporting about those data, support for annual and planned education, and specifics, such as handwashing and medication administration, were addressed. Also, this report identified the importance of governing boards understanding the issues of safety and propelled the idea of the chief nursing officer participating in board meetings in organizations that had not already embraced this practice. Redesigning both the work of nurses and the workspace was acknowledged as critical to maximizing a positive workforce.

Two other related reports in what is called the Chasm Series also provide guidance to nursing. These reports—Improving the Quality of Health Care for Mental and Substance-Use Conditions (IOM, 2005) and Preventing Medication Errors (IOM, 2006)—address two common encounters in healthcare organizations. Many patients who arrive at a hospital for medical or surgical intervention come with an underlying mental health or substance-use condition that complicates the basic intervention strategy. Also, medication errors are the source of many issues about patient safety. Almost all hospitalized patients and most people who have a healthcare condition and are not hospitalized use medications. The prevalence of the numbers of medications that pass hands in any organization alone would justify the work of this report.

Each of these reports fits within the IOM’s focus on quality and an attempt to make health care a quality endeavor. Together, these reports and others to be developed provide direction for the delivery of care and contain implications, if not outright recommendations, for nursing. These reports form the core of the work around quality in most organizations today. Further, they support many issues nurses have identified as key to quality care.

Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) is the primary Federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care (Agency for Healthcare Research and Quality [AHRQ], 2008). As seen in numerous IOM reports, recommendations about what AHRQ could do to enhance safety were prominent. AHRQ’s website (www.ahrq.gov) is an information-rich source for providers and consumers alike. For example, several healthcare conditions are identified in the outcomes research section. Because AHRQ maintains current information, it is a readily available source, even if the number of conditions is limited. Another example of AHRQ’s work is the fairly well-known “Five Steps to Safer Health Care,” which is available at www.ahrq.gov/consumer/5step.htm. Nurses who work in clinics will find these steps especially helpful in working with patients. This list identifies ways in which nurses can support people in assuming a more influential role in their own care. Further, supporting people in assuming a larger role helps them receive care that is patient-centered. Box 2-3 lists the five steps.

BOX 2-3

Five Steps to Safer Health Care