EXTERNAL THREATS TO PATIENT SAFETY

Threats to patient safety, such as errors perpetuated by a large health care system, necessitate that management and nursing staff develop surveillance systems for patient safety. Activities that promote patient safety, such as preventing hospital-acquired infections, are usually integrated into the quality assurance programs of hospitals. We have also considered the practice breakdown category of lack of preventive interventions. Researchers have recently examined the importance of staffing and its impact on patient safety (Blegen, Good, & Reed, 1998; Buerhaus et al., 2002; Clarke, Sloane, & Aiken, 2002). Planning for adequate nursing care is evaluated through staffing ratios determined by patient care needs. Higher patient acuity or complex care patients require more nursing care and surveillance and, ideally, nurse-patient ratios are adjusted accordingly.

PATIENT-RELATED VULNERABILITIES

The Practice Breakdown Advisory Panel found that patients with cognitive or sensory impairments were at greater risk for practice breakdown, suggesting that a higher nurse-to-patient ratio is also needed for these patients. Examining incidents of practice breakdown can assist with improving the design of the infrastructures related to promoting patient safety.

Safe and accurate nursing interventions depend on adequate patient monitoring, adequate planned safety measures to match patients’ specific needs, and good clinical judgment (Benner, Hooper-Kyriakidis, & Stannard, 1999). Much of the safety work of nurses is taken for granted because it is so pervasive and essential to patient well-being.

The following is an overview of important patient vulnerabilities that require examination to ensure appropriate and adequate nursing interventions:

1. Interventions to Protect Patients From Vulnerabilities Due to Illness, Disability, Age, and Cognition. Even under the best of circumstances, hospitalization may present potential hazards to patients. Much of the work of nursing has to do with ameliorating or preventing these hazards. The first class of hazards points to the vulnerabilities related to the patient’s illness, disabilities, age, or cognitive functioning. For example, patients with cognitive impairments may not be able to make adequate requests for help, or a family with an ill child must provide information about the child’s daily routines, medical history, preferences, and capacities without which gaps occur in medical treatment and nursing care. Frail elderly persons, infants, children, and persons with disabilities require specific planning to communicate their needs and provide for their safety in the hospital. Individualized measures for patient safety require planning and communication of potential hazards to prevent patients from falling, from receiving medications or foods that cause allergic responses, and from many other hazards specific to particular patients.

2. Interventions to Prevent the Hazards of Patient Immobility. A second class of potential injuries relates to decreased mobility or immobility in patients who are bedridden (Olson, 1967). Nurses intervene to prevent the hazards of immobility such as muscle contractions, stasis pneumonia, poor oral hygiene, and risks of patient falls. Patients with impairments that prevent normal eating need monitoring to provide adequate nutrition. Poorly timed or selected interventions to prevent patient safety hazards typically show up as lack of preventive measures. Typically, when errors of “omission” occur (such as a lack of intervention in potential patient safety hazards) (see Chapter 6), they are discovered in patient outcomes when it is too late to prevent the hazard. For example, a patient may develop “foot drop” when exercises, ambulation, footboards, or splints are not used early in the patient’s care. Consequently, on the TERCAP tool, the Prevention and Intervention categories are often both chosen as the major “types” of errors.

A major nursing goal in the care of elderly persons is to maintain or increase the functional capacities that they had on admission to the hospital. If specific nursing interventions are not undertaken, elderly patients will frequently lose the functional capacities that they had prior to hospital admission. For example, as little as one week with minimal ambulation may require special interventions in assisting elderly patients to regain the ability to walk safely. Loss of bladder control can be a major deleterious outcome of hospitalization or any institutionalization of older patients.

Clearly, even with timely nursing interventions to prevent immobility, all hazards may not be prevented in all patients. For example, a patient may be too unstable physiologically (e.g., because of compromised hemodynamics), or even psychologically, to complete all of the physical therapy that would be required to prevent muscle wasting.

Improved technologies have been developed to help prevent hazards of immobility. For instance, specialized beds that alternate pressure points and assist with patient positioning have been implemented to improve the care of comatose patients. Nurses have demonstrated the effectiveness of nursing measures to prevent most of the hazards of immobility most of the time for most patients. For example, the incidence of pneumonia for patients on ventilators has decreased dramatically with nursing interventions of hand hygiene, frequent and effective mouth care, and patient positioning (Hsieh & Tuite, 2006).

3. Interventions to Prevent Nosocomial Infections. A third class of hazards has to do with the dangers of nosocomial infections. Patients who are immunocompromised are particularly at risk, but any patient may acquire an infection from breaks in sterile technique or from lack of or inadequate hand washing on the part of nurses and other health care workers. Some procedures that use continuous intravenous fluids, drainage tubes (such as urinary catheters), chest tubes, and nasogastric tubes require monitoring and specific interventions to lower the possibility for infections.

Preventing infections requires vigilance on the part of all health care workers; however, nurses have a primary responsibility in designing and implementing surveillance systems and preventive procedures, such as rotation of intravenous sites, dressing changes, and general hygiene for patients. For example, routine lab work is checked daily to determine whether it is still necessary. Nurses share an informal maxim that if a technical intervention is not helping or needed, then it is potentially harmful to the patient (Benner, Kyriakidis-Hooper, & Stannard, 1999).

4. Interventions to Prevent the Hazards of Technology. A fourth class of potential threats to patient safety has to do with the hazards of technology, such as the potential for electrical shock, malfunctioning equipment, or even inadequate supplies and equipment (Benner, Hooper-Kyriakides, & Stannard, 1999). Nurses play an integral role in the safety work required for preventing and maintaining infrastructures that monitor and intervene with potential hazards in highly technical health care environments.

Surgical patients are all at risk for hypothermia, inadequate grounding of electrical equipment, inadequate securing and positioning, and all of the potential hazards that occur when a patient is unconscious and is not able to withdraw from painful stimuli or complain of pain.

One of the cases reported to a state board involved inadequate securing of the patient on an operating room table. The patient fell to the floor during the surgery, breaking all sterile techniques. Fortunately, measures were taken to treat the patient’s potential infection, no broken bones or major tissue injury occurred, and the patient recovered satisfactorily. Full disclosure was made to the patient and family soon after the surgery.

5. Interventions to Rescue Patients and Problems With Failure to Rescue Patients. Aiken and colleagues (2003) have used “failure to rescue” as a measure to assess the effectiveness of medical treatment and nursing care. Failure to rescue reflects a belief that institutional and staff resources can prevent or intercept patient catastrophes. These resources involve surveillance and effective rescue interventions (Clarke & Aiken, 2003) (see Chapter 4) for monitoring and recognizing the need for intervention. This combination of attentiveness and effective nursing interventions provides an essential foundation for safeguarding patients who may have compromised defense mechanisms due to illness and institutionalization.

Earlier, Aiken, Smith, and Lake (1994) conducted an epidemiologic study to evaluate the impact of nursing care on patient outcomes. They matched 195 control hospitals with 39 original magnet hospitals. The magnet hospitals had been formally evaluated and recognized for their quality of nursing care. The investigators used propensity scoring, a multivariate, matched sampling procedure that controlled for size, teaching status, technology, proportion of board-certified physicians, and selected hospital characteristics.

They found a 4.5% lower Medicare mortality rate in the magnet hospitals compared to the control hospitals not identified for their high quality of nursing care. They concluded that the quality of nursing care interventions has an impact on patient mortality and that failure to intervene appropriately to rescue patients in extreme circumstances contributed significantly to higher mortality rates in the control hospitals.