REPORTING TO LEARN AND REDESIGN THE SYSTEM

If the hospital culture has not progressed to a “just culture” focused on practice improvement and prevention, then incident reports are likely to be perceived as punitive in the work environment. Also, if nothing changes as a result of reporting the error or a near miss, it may seem to the worker that it is a waste of time to focus on error reporting (Sprenger, 2001). The reporting system needs to be designed for learning, accountability, and redesign that prevents the likelihood the same error will reoccur (Tokarski, 2001). Too often, adjustment and correction of errors, if they occur, take place in a vacuum with only a select few individuals knowing about the incident (Sprenger, 2001). Sharing the experiences of the error or the factors that could have led to an error, facilitates an opportunity for learning that will only occur when the fear of punitive action is eliminated from within the health care environment, and positive rewards and recognition are given for quality improvement through redesigning a safer system.

THE COST OF ERRORS IN HEALTH CARE

The Institute of Medicine (IOM) 1999 report To Err Is Human: Building a Safer Health System indicated that between 44,000 and 98,000 people die each year as a result of medical errors (Kohn, Corrigan, & Donaldson, 2000). Medical errors rank as the eighth leading cause of death exceeding motor vehicle accidents, breast cancer, and AIDS. A 1998 report from the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry identified medical errors as one of the four major challenges in improving the quality of health care. The IOM report estimates that the cost of medical errors is in excess of $37 billion per year (Kohn, Corrigan, & Donaldson, 2000). Approximately half of this cost is associated with preventable errors. Additional costs include loss of trust by patients and families and diminished satisfaction for patients and health care professionals (Sprenger, 2001). Yet too often, silence continues to surround errors and practice breakdowns.

In the 2001 IOM report Crossing the Quality Chasm (Committee on Quality of Health Care in America, 2001), six aims for improving the quality of health care were identified: (1) patient safety, (2) patient centeredness; (3) effectiveness; (4) efficiency; (5) timeliness; and (6) equity. Patient safety without these six intertwined patient care goals cannot be achieved. Safe care also must be high-quality care. Also, the focus on quality must be based on continual experiential learning, assessment, reflection, and correction and redesign of care to improve the quality.

Research shows that most (70%) medical errors can be prevented (Agency for Healthcare Research and Quality [AHRQ], 2000). Most agree that recognizing and admitting errors and promoting improvement are far better strategies than denying the occurrence of the error or support of denial and cover-up through encouraging retribution and punitive sanctions (Kohn, et al, 2000). The best practices for preventing and managing errors continue to require research (Kizer, 2001).

NURSES AND PREVENTION

Nurses, because of their generalist education, continuous presence with patients, and tradition of patient advocacy, play a key role in the reduction of error in health care today (Benner et al., 2002). Nurses and nursing assistive staff comprise the majority of the health care providers. Patients have the most contact and spend the greatest amount of time with nurses. Patients and their families depend on nurses to provide safe care at a most vulnerable time in their lives. Vigilance and engagement in self-monitoring are continuously required yet are often overlooked factors that can prevent errors (Liolios, 2003). According to Borrell-Carrio and Epstein (2004), evidence suggests that errors do not often result from a lack of knowledge, but rather they occur because of “the mindless application of unexamined habits and the interference of unexamined emotions” (Borrell-Carrio & Epstein, 2004, p. 310).

Patient interactions with health care professionals are essential elements in the recognition and prevention of errors. Including the patient as a partner in health care may also increase patient safety. For example, if patients are aware of their own medical history and know the medications they are taking, and the medications to which they are allergic, they are better able to identify possible errors and injuries regarding their own health care than if they are not aware of and knowledgeable about these factors. Further, they may be able to actually intercept an error at some point in time and enhance their own safety (Weingart et al., 2005).

Kizer (2001) recommended that health care providers conduct self-assessments or audits to identify patient safety hazards and improve care processes. Examining prevention from a proactive rather than a reactive stance may strengthen the possibility of eliminating the punitive aspects and focus on root causes of errors.

Nurses learn early in their education the basic fundamentals of providing care. Prevention is so intertwined in nursing fundamentals that it is difficult at times to separate it. The increased demand on nurses has caused many nurses to function and work in an overload capacity, which ultimately may cause substandard patient care.

Often prevention becomes second nature and includes taking precautions to avoid infection, positioning patients, and other commonly practiced interventions. Jastremski, a registered nurse from Rome Memorial Hospital in Rome, New York, evaluated the occurrence of errors in the ICU. She noted that the simple task of hand washing may be omitted or done improperly because of increased demands, resulting in increased rates for nosocomial infections (Liolios, 2003).

Some examples of practice breakdown related to prevention include:

PROTECTING SPECIFIC PATIENT VULNERABILITIES

Even under the best of circumstances, hospitalization presents hazards to patients. Much of nursing work has to do with ameliorating or preventing these hazards. The first class of hazards has to do with the vulnerabilities related to the patient’s illness, disabilities, age, or cognitive functioning. For example, patients with cognitive impairments may not be able to request help adequately. Children’s families must provide information about a child’s daily routines, health status and growth pattern, medical history, preferences, and capacities. Infants, children, persons with disabilities, and the elderly require specific planning for communicating their needs and providing for their safety in a hospital. Patient safety requires specific planning and communication of specific potential hazards to prevent patients from falling, from receiving medications or foods that cause allergic responses, and from other hazards specific to particular patients.

THE HAZARDS OF PATIENT IMMOBILITY DURING HOSPITALIZATION

A second class of potential injuries relates to decreased mobility or immobility in patients who are bedridden. Nurses attend to the hazards of immobility, such as muscle contractions, stasis pneumonia, poor oral hygiene, and the risks of patient falls. Nutrition has to be monitored for patients with impairments that may prevent normal eating. A major challenge for elderly persons who are hospitalized is that they lose functional capacities that they had prior to hospitalization. For example, one week with little ambulation may require special interventions in assisting elderly patients to regain their ability to walk safely.

It is reported that 2.5 million patients are treated for pressure ulcers annually in the United States, and more than 50,000 patients die as a result of complications related to pressure ulcers (Ayello & Braden, 2002; Lyder, 2003; Reddy, Gill, & Rochon, 2006). Prevention of decubitus ulcers depends on many factors directly associated with standard nursing interventions aimed at preventing complications due to immobility, such as hygiene, hydration, electrolyte balance, nutrition, adequate and frequent positioning, use of support devices to protect patients’ skin and bodies in bed, and more such hazards associated with particular patient morbidities related to bed rest and immobility.

Prevention of venous thromboembolism (VTE) requires attending to the risk factors for VTE, such as immobility, inactivity, specific disease processes such as cancer, nephrotic syndrome, heart failure, indwelling urinary catheters, and more (Wachter, 2008). Pulmonary embolism is especially dangerous to patients who are compromised by heart failure and other comorbidities. Autopsy studies have shown that almost half of the patients who die in the hospital will have had a pulmonary embolism, which is often undiagnosed prior to death (Shojania et al., 2003). The following risk factors for patient falls in the hospital (Currie, 2008) based on STRATIFY (St. Thomas Risk Assessment Tool in Falling Elderly Inpatients) are identified in Table 6.1.

TABLE 6.1 Risk Factors for Patient Falls in the Hospital

From Bogardus, S.T. (2003). Risk factors for falls in the hospital. In: Another fall [Spotlight]. AHRQ WebM&M (Serial online). Available online at http://www.webnn.ahrq.gov. See also: Agostini, J.V., Baker, D.I., Bogardus, S.T. (2001). Prevention of falls in hospitalized and institutionalized older people. Rockville, MD: The Agency for Healthcare Research and Quality. Currie, L. (2008). Fall and injury prevention. In Hughes R.G. (Ed.). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Available online at www.ahrq.gov/qual/nurseshdbk/. Accessed November 14, 2008.

Checklists are central to ensuring ongoing good and improving prevention in health care institutions (Gawande, 2007; Pronovost, Miller, & Wachter, 2006; Pronovost, Weast, & Rosenstein, 2005), and nurses are central to the effectiveness of implementing and maintaining adherence to checklists (Gawande, 2007). New efforts aimed at assessing risk factors for falls and prevention of decubitus ulcers and contractures now include preventive checklists. Maintaining functional status during hospitalization, especially for elderly patients, is impossible if the initial assessment of the patient’s functional status is incomplete and the daily functional status is not checked against the initial functional status.