Evelyn D. Quigley, RN, MN
Patient safety has become a national priority. This article discusses the contributions of the professional, public, and private sectors regarding patient safety. Definitions and detailed examination of the issues surrounding patient safety are presented. Ideas to create improved systems for the important issue of patient safety are explored. The opportunity for increased interaction among the various groups has great potential. Health care organizations that exemplify best practices in patient safety will be rewarded by the purchasers of health care and by accreditation agencies. The Leapfrog Group and the Joint Commission on Accreditation of Health Care Organizations are leading this effort. Nursing has a major role in leading efforts to find solutions to advance patient safety standards.
Citation: Quigley, E., (September 30, 2003). "Contributions of the Professional, Public, and Private Sectors in Promoting Patient Safety". Online Journal of Issues in Nursing. Vol. 8 No. 3, Manuscript 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/ContributionsinPromoting.aspx
Key words: Safety, disclosure, Institute of Medicine, Leapfrog Group, sentinel events, medical errors, root cause analysis, failure mode effect analysis, computerized physician order entry, bar-coding, adverse drug events, patient-centered care, Center for Medicare and Medicaid, and Joint Commission of Accreditation Health Care Organizations.
Patient safety has become a national priority. The purpose of this article is to discuss the contributions of the professional, public, and private sectors regarding patient safety and to explore options in creating improved systems for this pressing issue. With increased complexity of the health care system, workforce shortages, decreased reimbursement, and more demand for services, the imperative to find solutions for safer care is even more urgent. The pace of work has increased considerably, along with greater interdependence among health care professionals and in the various health care settings. This interdependent relationship calls for more frequent transfer of care from one professional to another, presenting frequent occasions for system failure and communication breakdown.
Additionally, due to the lack of integrated technology and appropriate decision support applications, steps to identify and reduce medical errors in health care have been impeded. Since the traditional reporting practice of health care settings has been to report one incident at a time, errors have been treated as singular incidents without regard to the frequency or intensity of impact. Due to malpractice and confidentiality concerns, the health care industry acknowledges that errors are generally underreported. Based on the unique response of individuals to medical treatment, medical errors can be difficult to recognize.
New safety standards will push health care institutions to be proactive rather than reactive in identifying and preventing potential sources of patient risk.
Strategies to create a safe care environment are being advanced from the professional, public, and private sectors. New safety standards will push health care institutions to be proactive rather than reactive in identifying and preventing potential sources of patient risk. How do health care organizations assist patients, families, and clinicians to deal with errors, failures, and accidents that result in harm? How do health care leaders cope with advocating open disclosure about errors and accidents in an industry that experiences negative publicity and high exposure to legal liability? An exploration of the contributions of various diverse constituencies will be conducted in pursuit of the potential for greater interaction with one another.
Responses by Professional Associations
American Nurses Association Response
While nursing has had patient safety as a primary focus, a coordinated and comprehensive system for patient safety has not existed. Various organizations have drawn attention to the need for the development and support of an integrated and comprehensive system that identifies and manages medical errors and rewards health care systems for positive outcomes. It was the American Nurses Association (ANA) Board of Directors that instituted the Nursing’s Safety & Quality Initiative in 1994 (ANA, 1999). Given the fact that considerable restructuring was occurring in the health care industry, this multi-phase Nursing’s Safety & Quality Initiative gave direction to the study of the impact of these changes on safety and quality of patient care as well as nursing. Numerous projects were launched from the investigation. Key focus was placed on educating registered nurses about "quality measurement, informing the public and purchasing/regulating constituencies about safe, quality health care, and investigating research methods and data sources to empirically evaluate the safety and quality of patient care" (ANA, 1999, p.1).
While nursing has had patient safety as a primary focus, a coordinated and comprehensive system for patient safety has not existed.
Of primary importance was the creation of a National Database of Nursing-Sensitive Quality Indicators (NDNQI). ANA defined nursing-sensitive quality indicators as "those indicators that capture care or its outcomes most affected by nursing care" (ANA, 1999, p.4). In 1998, ANA funded the development of the national database for the nursing-sensitive quality indicators. The database was located at the Midwest Research Institute (MRI) in Kansas City, Missouri. The MRI and the University of Kansas School of Nursing jointly managed the database. The purpose of the NDNQI was to "promote and facilitate the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes" (ANA, 1999, p. 8). Hospitals have used the results from the database to make internal comparisons of their nursing quality and patient outcomes while also making comparisons of their performance with like organizations. Because health care organizations accredited by the Joint Accreditation of Health Care Organization (JCAHO) are required to meet JCAHO 2002 staffing effectiveness standards, this database serves as an invaluable tool for nurse executives to effectively compare staffing patterns and methods with clinical outcomes (Runy, 2003). Presently, the NDNQI is housed at the University of Kansas School of Nursing with fiscal/legal support from the MRI and a participation of over 347 hospitals in 48 states and the District of Columbia.
Current studies validate the linkage between nurse staffing and outcomes of patient care. Aiken, Sean, Sloane, Sochalski, and Silber (2002) found links between high patient-to-nurse ratios, increased mortality rates among surgical patients, and the increased likelihood of nurse burnout and dissatisfaction. The study reported that mortality rates among surgical patients increased seven percent for every additional patient added to the average nurses’ workload. The additional patient assignment contributed to a 23 percent increase in the odds of nurse burnout. Needleman, Buerhaus, Mattke, Stewart, and Zelevinsky (2002) in their study concluded that a higher proportion of care provided by registered nurses and a greater number of hours of care by nurses per day are associated with positive patient care results. Some of the outcomes found were shorter lengths of stay, fewer urinary tract infections, and fewer cases of upper gastrointestinal bleeding for hospitalized patients.
American Medical Association Response
Another organization to study patient safety was the American Medical Association (AMA). By establishing the National Patient Safety Foundation in 1997, the AMA commissioned the Foundation to conduct a national survey to address patient safety issues in the health care environment (Harris & Associates, 1997). The findings from the national telephone survey of 1513 respondents indicated that "the health care environment was perceived by the general public as ‘moderately’ safe" (Harris & Associates, p. 3). The respondents stated that "carelessness or negligence on the part of health care professionals was the main cause of errors"; while, "the second most cited reason for medical errors was related to health care professionals being overworked, hurried and stressed" (Harris & Associates, p. 5). It was noted that 95 percent of the respondents would report a medical mistake if they encountered one (Harris & Associates). Recommendations were proposed for preventing medical mistakes. The major suggestions were to improve oversight of caregivers; ensure appropriate qualification and training of health care professionals; provide physician information to consumers; create an independent organization to examine the causes of medical mistakes; and increase the public’s awareness of the issues surrounding errors (Harris & Associates). Organizations may consider replicating this survey in order to have a greater understanding of their customer needs.
First Institute of Medicine Report and Responses
The most significant study that not only galvanized the health care industry but elevated the awareness of the public on patient safety was the Institute of Medicine (IOM) report on medical errors, entitled To Err is Human: Building a Safer Health System released in 1999 (Kohn, Corrigan, & Donaldson, 2000). The findings of the report produced a substantial media, public, Congressional, and departmental response regarding concern for patients’ health and safety.
...over half of all errors investigated were preventable.
According to the IOM report, in-hospital errors account for as many as 44,000 to 98,000 deaths each year in the United States. The IOM provided the following definition: " An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning)" (Kohn, et al.
, p. 28). The study addressed errors in acute care hospitals but did not include data about care delivered in clinics, homes, rehabilitation centers, psychiatric facilities, or long term care settings. It reported that in one year, more people die from medical errors than from breast cancer, AIDS, or motor vehicle accidents. Errors also caused injuries to patients; adverse events occurred in three to four percent of hospitalized patients, while one in ten resulted in death. Errors occurred in virtually every hospital in the country. According to the study, medical errors were also costly. Total national costs were projected between $17 and $29 billion each year. Medication errors, which were among the most common errors, tacked on an additional $4,700 to the average hospital bill each time they occurred. Most importantly, over half of all errors investigated were preventable. A major finding of the IOM report was that these errors occurred because of system failures rather than people problems; and preventing errors required designing safer systems of care (Kohn, et al.
To help improve systems of care, the IOM report recommended a four-part plan for government and health care settings. The plan set forth the following recommendations:
- Establish a national center for patient safety
- Develop reporting systems to identify and learn from errors
- Raise standards for safety through regulatory and market forces
- Create safety systems in health care organizations at the care delivery level (Kohn, et al., 2000, p. 6).
This first IOM report prompted considerable debate regarding the accuracy of the actual numbers of errors. Since the focus of the report was placed on errors occurring in hospitals, little is known regarding the number of errors or frequency of occurrence in home care, ambulatory care, nursing homes or hospice settings. In addition, the report left the accountability for error management unclear by recommending both internal and external oversight. Porter & Malloch (2002) proposed that managing errors closest to the point of occurrence resulted in performance improvement, especially, when a standardized national repository exists. In contrast, the authors indicated that external control reinforced a culture of blame.
On the other hand, the IOM report generated action from both the public and private sector. Within the public sector, President Clinton immediately ordered a government feasibility study. Based on the findings of the study in 2000, the President mandated that the IOM recommendations be implemented. Specifically, a 50 percent reduction in medical errors was to be achieved within the next five years. To further advance these directives, the President mandated that all 6,000 hospitals participating in the Medicare program implement patient-safety initiatives, including medications and safety-oriented approaches (Kimmel & Sensmeier, 2002).
Agency for Health Care Research and Quality Response
As described in the IOM report, a recommendation was made for the Agency for Health Care Research and Quality (AHRQ) to create a Center for Patient Safety having accountability to the President and Congress (Kohn et al., 2000). To promote the patient safety agenda, the AHRQ received a $50 million grant to fund error-reduction research. It is interesting to note that the amount allocated by Congress for safety research in 2002 was less than half of one percent of the National Institute of Health budget for important medical research (Leape, Berwick, & Bates, 2002). The first effort of the AHRQ to investigate patient safety from an evidence-based medicine approach was published in a report titled Making Health Care Safer: A Critical Analysis of Patient Safety Practices (Shojania, Duncan, McDonald, & Wachter, 2001). The report was a result of a commissioned group of 40 researchers, including experts in patient safety, evidence-based medicine, and various areas of clinical medicine, nursing, and pharmacy (Skojania, Duncan, McDonald, & Wachter, 2002). The research was conducted from a systemic approach addressing diseases and procedures. Results were reported by opportunities for safety improvement and for research. Evidence-based medical approaches were found to be as vital for advancing the patient safety agenda as were the advances proposed in the non-medical field, such as bar-coding, simulation, and computerized physician order entry. The report called for greater emphasis on engaging the clinicians in the workplace to decrease risks attributed to care practices (Shojania et al., 2002).
The report received considerable attention. Some opposition surfaced regarding applying the principles of evidence-based medicine to patient safety practices. The method for the prioritizing of action items to improve patient safety were challenged and recommended for future research (Leape, et al., 2002). However, there was agreement that the practice of anesthesia was an outstanding example of how a high level of safety could be achieved in health care. The success of this achievement was based on a broad range of changes in process, technological advances, training, and teamwork.
The Leapfrog Response
In addition to government agencies, the private sector also responded to the first IOM report. The Business Roundtable (BRT) formed a new program called "The Leapfrog Group," a coalition of Fortunate 500 companies and other large private and public health care purchasers. Under Leapfrog, employers have agreed to base their purchase of health care on principles encouraging more stringent patient safety measures. These measures included computerized physician order entry, evidence-based hospital referral, and intensive care unit staffing by physicians trained in critical care medicine (Birkmeyer, Birkmeyer, Wennberg, & Young, 2000). There has been a positive response from the marketplace. Recently, the Leapfrog Group has been joined by JCAHO increasing the original membership of 60 purchasers to more than 90 and now representing 25 million beneficiaries (Kimmel & Sensmeier, 2002).
Quality Interagency Coordination Task Force Response
The Quality Interagency Coordination Task Force (QuIC) who received direction from the President reported more progress on the IOM recommendations. In order to consider all the important implications of medical errors, the QuIC proposed an expansion of the IOM’s definition of medical errors. The QuIC defined an error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems" (U.S.Department of Health and Human Services [U.S.DHHS], 2003b, p. 3435). The Center for the Medicare and Medicaid Services (CMS), an agency of the Department of Health and (U.S.DHHS), adopted the revised definition and published the results in the Federal Register (U.S.DHHS, 2003b). This expanded definition allowed for the identification of possible factors leading to errors, such as seclusion, restraints, equipment failures, and blood transfusions.
In the AHRQ evidence report, the term "error" was not included in the definition in order to minimize a negative connotation and because of the difficulties in specifying what constitutes a medical error. Rather, the authors defined a patient safety practice as a "type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures" (Shojania, et al., 2002, p. 508).
For years, patient errors have primarily been addressed through malpractice litigation. Prior to the publication of the 1999 IOM report, the emphasis on having patients actively involved in error prevention was minimal. Organizations lack the processes to make the transition from a risk management environment of identification and discipline of individuals to a cooperative, system-based pursuit of improvement (Kohn, 2000). Because risk management is typically framed as a professional approach, organized medicine, on one side, and the trial bar, on the other, with patients the object of discussion and seldom involved in the process, the method for consistent patient involvement has not been designed (Sage, 2002). Forging stronger links with customer satisfaction and the clinical safety focus of the health system could be a start. In the review of several studies, Sage proposed that reducing lawsuits requires preventing errors and not just placating patients. Approaching legal aspects from a customer-focused perspective, would not only control legal costs, but would also aid in conducting more reliable statistical analysis of medical practices in order to seek opportunities for improvement. With greater emphasis on advanced technology, "acting on the signals offered by patient complaints, therefore, can reduce both physician and interpersonal harm to patients"(Sage, p. 3004).
...a considerable amount of focus needs to be placed on moving from an adversarial, legal approach to a more inclusive, collaborative approach with the patient and family.
As was previously found in the AMA study, consumers offered several recommendations for preventing medical errors. Health care organizations are challenged to create innovative systems for engaging patients and their families in efforts to take action on steps following errors or on reporting near misses. Most recently, hospitals have endorsed polices and procedures to disclose such situations when they occur. However, a considerable amount of focus needs to be placed on moving from an adversarial, legal approach to a more inclusive, collaborative approach with the patient and family. Tools are available to assist health care organizations to assess their performance in this area. One such instrument, The Patient Safety Organizational Assessment Tool, developed by Wilson, provides a systematic method to evaluate current processes and systems and measure ongoing progress in establishing a safer environment (Sarudi, 2001).
Second IOM Report and Response
In March 2001, the Committee on the Quality of Care in America produced the second IOM report Crossing the Quality Chasm: A New Health System for the 21st Century. The focus of this IOM publication was a call for action to improve the nation's health care delivery system. With the aging of America, greater demand for services, and advanced technology and drugs, health care costs were increasing as resources were being overutilized. This report, like the first IOM report, repeatedly addressed patient safety problems with a major emphasis on redesign of the system. Six specification areas were recommended as significant when revamping the health care delivery model. These specification areas are: "patient safety, patient-centered care, efficiency, effectiveness, timeliness, and equity" (Committee on the Quality of Care in America, 2001, p.6).
Again, the public sector responded when the CMS promulgated a new rule instructing hospitals to develop and implement quality assessment and improvement programs (QAPI) to identify patient safety issues and to decrease medical errors. The rule, Medicare Conditions of Participation (CoP), for hospitals went into effect on January of 2003 (U.S.DHHS, 2003a). U.S.DHHS Secretary Tommy G. Thompson said:
This rule will encourage a greater emphasis on patient safety in hospitals. This serve as another step toward bringing improved patient safety, accountability and quality to the forefront of medical practice. Ultimately, we hope to create an environment where hospitals and other providers compete based on the quality of care that they provide to their patients (U.S.DHHS, 2003a, p.1).
Specifically, the QAIP of hospitals must reflect the complexity of the organization and services, be organizational-wide, focus on maximizing quality of care outcomes, and include preventative measures to promote patient safety. The expectation of the mandate is to ensure uniformity in quality standards for all Medicare participating hospitals.
National Nursing Home Response
...many of these indicators are descriptive of the nursing-sensitive indicators developed by the ANA.
In November of 2002, CMS released nationwide data on quality measures of each nursing home in the United States. This national Nursing Home Quality Initiative (NHQI) was introduced to assure higher quality of care provided to Medicare and Medicaid beneficiaries. In addition to the previous reporting requirements, CMS contracted with the National Quality Forum (NQF) to develop 10 quality measures for consumers to compare the quality of nursing homes (NDHCRI, 2002). It is interesting to note that many of these indicators are descriptive of the nursing-sensitive indicators developed by the ANA. A comparable initiative requiring home health agencies to measure patient safety outcomes is expected to be announced by CMS in 2003 (U.S.DHHS, 2003a).
The demand for improvement in patient safety has been validated by the public, private, and regulatory sectors. Responding to the challenge offered by IOM, groups such as JCAHO, Leapfrog Group, AHRQ, and the Institute for Safe Medication Practice (ISMP), all have taken action to elevate the importance of patient safety and in some instances have points of intersection from their various recommendations. One such agreement was the need for greater education and training as it related to look alike/sound alike drugs. All addressed the big challenge of transforming the internal environment into a culture that embraced safety and delivered high reliability services. Additionally, transforming the external environment into a collective model of accountability was proposed to be equally challenging. With the recent alliance between JCAHO and the LeapFrog Group, health care leaders are faced with having to meet the new patient safety standards set by regulatory agencies and the marketplace.
Over the past years, JCAHO has answered the call by the IOM for greater accountability.
Over the past years, JCAHO has answered the call by the IOM for greater accountability. One of the actions taken was to redesign the accreditation process. The direction of the revised process has been to concentrate on systemic recommendations and promote a non-prescriptive approach with the exception for sentinel review and reporting. JCAHO defined a sentinel event as " unexpected occurrences involving death or serious physical or psychological injury, or risk thereof, which signal the need for immediate investigation or response" (Levy, 2001, p.10). In 2001, JCAHO put into effect new standards requiring organizations to create a culture of safety; to implement a safety program with a specific visible administrative leader assigned the accountability for patient safety; and to disclose to patients the outcome of their care. Disclosure followed an earlier standard, when hospitals were required to report any incident of patient harm or death related to medical error, and to conduct an intensive review of the case. The methodology for analyzing these sentinel events was called a "root cause analysis" (RCA) and is grounded in industrial safety methodology (Kirkpatrick, 2003). The purpose of a RCA review was for hospitals to develop an action plan to ensure that the factors leading up to the sentinel event were resolved. Additionally, the JCAHO published the Sentinel Event Alert, which described actual cases and was intended to educate the hospitals regarding errors that were occurring. The publication was also intended to stimulate a proactive stance so that organizations would examine their work processes and make the necessary changes. Levy (2001) indicated that perhaps the most controversial aspect of the redesigned approach by JCAHO is the requirement for health care givers to inform patients and their families when results of a procedure or action is not what was expected.
Based on a rigorous review of the reported sentinel events, the JCAHO in 2002 approved its first set of six National Patient Safety Goals (JCAHO, 2003b). These six goals with measurable objectives were intended to standardize the risk-reduction tactics used by health care organizations. Kirkpatrick (2003) indicated that by having organizations approach patient safety in a uniform way, JCAHO would be able to measure the effectiveness of setting key strategies. All hospitals will be required to comply with the six patient safety goals in future JCAHO surveys starting in 2003. "Failure to implement one or more of the recommendations (or acceptable alternatives) will result in a single special Type I recommendation" (JCAHO, 2003b, p.2). The six key issues determined for compliance include accurate patient identification, effective communication, safe use of high-alert medication, elimination of wrong-site surgery, safe use of infusion pumps, and safe use of clinical alarms (Kirkpatrick). Each of the six standards and their implications for nursing practice will be described below.
Nursing practice will influence all of the new standards on patient safety and outcomes of care. Nurses, by the very nature of their professional knowledge and skill are critical resources to the organization. Nurses need to be given a strong and rightful place in decision making about issues relating to clinical practice. Nurses will affect patient safety in all health care settings. While the focus of the IOM study has been on acute care settings, nurses serve as the patient and family advocate no matter what setting of health care is required. With the advent of more procedures taking place in ambulatory settings, the potential for more injury to patients exists. Today, 65 percent of all surgical procedures do not involve a hospital stay (Lapetina & Armstrong, 2002). The intent of developing the nursing-sensitive indicators was to provide nurse executives with more definitive data to demonstrate the clear linkages between nursing interventions, staffing levels, and positive patient outcomes (ANA, 1999). The importance of advancing the nursing-sensitive quality measures for use in publicly available reports cards cannot be over emphasized. As previously noted, the Nursing Home Quality Initiative mandated by the CMS is an example of the power of ANA’s Nursing Safety & Quality Initiative of 1994.
Nurses need to be given a strong and rightful place in decision making about issues relating to clinical practice.
Nurses will provide considerable leadership to the implementation of the JCAHO patient safety goals. The first standard, accuracy of patient identification, has two components. One, organizations are required to establish two patient identifiers, other than the patient room, such as patient’s name, date of birth, or hospital identification number. The other component of this goal is to have a rigorous verification process followed on any surgical or invasive procedure to ensure correct patient, procedure, and site. Involving key stakeholders, such as nurses, in formalizing the two patient identifiers provides the opportunity for the organization to clearly establish indicators and measurement criteria at the same time. Standardizing the current (manual) process would increase understanding and support so hospitals could prepare for future bar coding technology.
Kirkpatrick (2003) stressed the fact that nurses needed to be more assertive when carrying out the second component of the identification requirement. Nurses need a routine method to ensure that the appropriate patient, the appropriate procedure, and the appropriate procedure site are verified in a consistent manner prior to the start of any surgical or other invasive procedures.
Nursing’s role is critical in meeting the intent of the effective communication standard on orders and symbols, the second safety standard. This standard requires the accurate transcription of verbal and telephone orders, and the appropriate interpretation of difficult or unclear written orders. The relationship between the nurse and the provider giving the order contributes considerably to the success of this standard, since nurses are required to read back any verbal or telephone orders given. Kirkpatrick (2003) reported that hospitals would be required to formalize an approved abbreviation, acronym, and symbol listing, as well as to formalize a list of abbreviations that are not permitted, with clearly defined consequences for those not complying. The most controversial aspect of this standard is to define the consequences of non-compliance when physician, nurses, and pharmacists are deviating from the organization policies and procedures.
Well-defined protocols developed by physicians, pharmacists, and nurses ensure safer use of high-alert medications. High-alert medications are those drugs which when misused have a "high risk of injury or death"(Cohen & Mandrack, 2002, p. 371). Because of their greater risk, special considerations are required when administering these drugs. Cohen and Mandrack (2002) reported that these high alert medications are packaged differently with visible warnings, stored differently so that they are separated from other medications, prescribed differently with standardized orders, and administered by requiring independent double-checking. Standardized protocols promote consistency of dosing calculation and methods of administration. Additionally, limiting the number of drug concentrations places additional control over medication errors. By standardizing the concentration of a medication, the dosing calculations are the same from one case to the other. Initiating protocols would not only provide direction for nurses in the administration of drugs, but also contribute to the development of educational tools and methods to verify consistency for patient and family education.
Previous reference was made to ensuring the correct identifier for the right patient. The major focus of the fourth safety standard is to eliminate wrong-site, wrong-patient, and wrong-procedure surgery. While the patient is very much involved with the process of site marking, another aspect of the standard is the verification process in the operating room. There are many similarities between the airline industry and surgical safety procedures. Airline safety processes include standardized procedures, checklists, explicit cross-checking, redundant checks, and a culture of equal accountability. Based on hundreds of little changes in work procedures, training, and system processes, aviation safety has established a strong safety culture (Leape et al., 2002).
Improving the safe use of infusion pumps is the fifth standard. The goal, specifically, requires infusion pumps to have a built-in protection from free-flowing fluids. Organizations can achieve this safety goal by involving nurses in the selection of products, setting minimum specifications for product evaluation, and defining the competencies required for nursing proficiency. Nursing education can schedule frequent educational skill development events to increase awareness of the safety features and ensure nursing proficiency through demonstration efforts. In addition, meeting this standard calls for a rigorous organizational maintenance program to serve as a check and balance system.
To meet the intent of the sixth safety standard, organizations would need to validate that an active preventive maintenance program exists, and that alarms are activated appropriately.
The sixth safety standard was designed to improve the effectiveness of clinical alarm systems. With the advanced technology, numerous alarms are available in patient care settings such as ventilator alarms, bed alarms, and pagers to name a few. A major deterrent in meeting this standard is the potential to mute an alarm to create a quiet environment for the patient. To meet the intent of the sixth safety standard, organizations would need to validate that an active preventive maintenance program exists, and that the alarms are activated appropriately. Reviewers would call for evidence of compliance such as logs, records, usage, and training of health care workers. As was detailed in the fifth standard, organizations have the prerogative to define minimum specifications and educational requirements for its users. Nursing has an opportunity to work closely with other departments within the health care setting as purchasing decisions are made and maintenance programs are established.
Close attention to meeting the patient safety goals will be ongoing. JCAHO has announced its 2004 national patient goals. The new release reported that all of the 2003 goals will be continued with the addition of a new goal that will concentrate on reducing the risk of acquired infections in health care settings (JCAHO, 2003a).
...patient safety will be a top priority agenda item for health care providers now and in the future.
There has been a convergence of thought among professional, private, and governmental health care decision makers that agree with the basic premise: patient safety will be a top priority agenda item for health care providers now and in the future. Various constituencies have contributed to the definition and detailed examination of the issues surrounding patient safety. In exploring the unique contributions of the major professional, public, and private groups, there are similarities and differences in the recommendations about the pathways to patient safety. All groups have validated the demand for improvement in patient safety. One agreement stated was the need for greater education and training as it related to look alike/sound alike drugs. Many of the constituencies addressed the big challenge of transforming the internal environment into a culture that embraced safety and delivered highly reliable services. Additionally, transforming the external environment into a collective model of accountability was proposed to be equally challenging.
Nursing has a major role in providing leadership in the creation of solutions to advance patient safety standards.
The potential for these groups to interact with one another in order to create even a stronger infrastructure for patient safety is enormous. In fact, organizations that exemplify best practices in patient safety will be rewarded by the purchasers of health care and by accreditation agencies. Forging stronger links with the consumer is an untapped opportunity. Furthermore, linking consumer needs with the clinical safety focus of the health care system has the potential to decrease the risk of malpractice and enhance relationships. Nursing has a major role in providing leadership in the creation of solutions to advance patient safety standards.
Evelyn D. Quigley, RN, MN
Evelyn D. Quigley received a Bachelor of Science in Nursing from Moorhead State University, Moorhead, MN, and a Master of Nursing with a Major in Nursing Administration and a Minor in Business Administration from the University of Washington, Seattle, WA. She is a Senior Executive of MeritCare Health System, Fargo, ND. Evelyn serves as Clinical Patient Safety Officer in partnership with a Physician Senior Executive for MeritCare. Recently, she was the Co-leader for the Idealized Clinical Office Practice Redesign Collaborative between VHA Upper Midwest, Minneapolis, MN, and the Institute of Health Care Improvement, Boston, MA. Evelyn is the Senior Executive Lead for a collaborative project on patient safety with VHA Upper Midwest, Minneapolis.
Evelyn is a member of the American Nurses Association, North Dakota Nurses Association, and presently the chair of the North Dakota Organization of Nurse Executives. She serves as an appraiser for the Magnet Recognition Program through the American Nurses Association Credentialing Center. She is a member of Sigma Theta Tau International Honor Society for Nursing through the Xi Kappa Chapter-at-large and ETA Upsilon Chapter.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H., (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association, 288(16), 1987-1993.
American Nurses Association [ANA]. (1999). Nursing Facts: Nursing – Sensitive Quality Indicators for Acute Care Settings and ANA’s Safety & Quality Initiative. Retrieved June 2, 2003, www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/NDNQI/Research/QIforAcuteCareSettings.aspx
Birkmeyer, J. D., Birkmeyer, C. M., Wennberg, D. E., & Young, M. P. (2000). Leapfrog safety standards: potential benefits of universal adoption [Monograph]. The Leapfrog Group. Washington, DC.
Cohen, H., & Mandrack, M. M., (2002) Application of the 80/20 rule in safeguarding the high-alert medications. Critical Care Nursing Clinics of North America, 14, 369-374.
Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National Academy Press.
Harris, L., & Associates. (1997). Public opinion of patient safety issues: Research findings. Commissioned for the National Patient Safety Foundation at the American Medical Association, September, 1997. Retrieved June 23, 2003 from www.npsf.org/download/1997survey.pdf
Joint Commission on Accreditation of Healthcare Organizations. (2003a) Joint Commission announces 2004 national patient safety goals. Retrieved July 25, 2003 from www.jacho.org/news+room/news+release+archieves/nsg04.htm
Joint Commission on Accreditation of Healthcare Organizations. (2003b). Facts about Patient safety. Retrieved on June 6, 2003 from www.jcaho.org/accredited+organizations/patient+safety/facts+about+patient+safety.htm
Kimmel, K. D., & Sensmeier, J. (2002). A technological approach to enhancing patient safety. [Monograph]. Healthcare Information and Management Systems Society. 1-7.
Kirkpatrick, C., (2003). Safety first: The JCAHO introduces new patient safety goals. NurseWeek, 4(2), 19-20.
Kohn, L.T., Corrigan, J. M., & Donaldson, M.. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.
Lapetina, E. M., & Armstrong, E. M., (2002). Preventing errors in the outpatient setting: A tale of three states. Health Affairs, 21(4), 26-39.
Leape, L. L., Berwick, D. M., & Bates, D. W. (2002). What practices will most improve safety? Evidence-based medicine meets patient safety. Journal of the American Medical Association, 288(4), 501-501.
Levy, D., (2001). New standards enable nurses to shape patient policy. NurseWeek, 2(9), 10-11.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. The New England Journal of Medicine, 346(22), 1715-1722.
Porter-O’Grady, T., & Malloch, K. (2002). Quantum Leadership: A Textbook of new leadership. Maryland: An Aspen Publication.
Quality Counts: Nursing Home Quality Initiative. (2002). Quality initiative to be conducted in nursing homes (ND-6SOW-O2-QP-32) [Brochure]. North Dakota Health Care Review, Inc.: Author.
Runy, L.A. (2003). Staffing effectiveness: A toolkit for JCAHO new standards. Hospitals & Health Networks, 77(3), 57-63.
Sage, W. M., (2002). Putting the patient in patient safety: Linking patient complaints and malpractice risk. Journal of American Medical Association, 287(22), 3003-3005.
Sarudi, R., (2001). Keeping patients safe. Hospitals & Health Networks, 75(4), 42-46.
Skojania, K.G., Duncan., B. W., McDonald, K.M., & Wachter, R.M.. (Eds.). (2002). Safe but sound: Patient safety meets evidence-based medicine. Journal of the American Medical Association, 288(4), 501-512.
Shojania, K. G., Duncan, B. W., McDonald, K. M., & Wachter, R. M.. (Eds.). (2001) Making health care safer:A Critical analysis of patient safety practices. Evidence Report/Technology Assessment, No.43. Prepared by the University of California at San Francisco-Stanford, Evidence-based Practice Center under contract No. 290-97-0013 for Agency for Healthcare Research and Quality; July 2001. Retrieved June 9, 2003, from www.ahcpr.gov/clinic/ptsafety/
U.S. Department of Health and Human Services. (2003a). CMS issues final quality assessment and performance improvement conditions of participation for hospitals. (Center for Medicare and Medicaid Services). Washington, DC.
U. S. Department of Health and Human Services. (2003b). Medicare and Medicaid Conditions of participation: Quality assessment and performance improvement (U.S.DHHS Publication No. 42 CFR Part 482). Washington DC: U.S. Government Printing Office.
© 2003 Online Journal of Issues in Nursing
Article published September 30, 2003
- Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings
Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN; Ellen Harper, DNP, RN-BC, MBA, FAAN; Nancy Barr, MSN, RN (April 14, 2015)
- Nurses with Undiagnosed Hearing Loss: Implications for Practice
Cara S. Spencer, MSN, FNP-BC; Karen Pennington, PhD, RN (January 5, 2015)
- Avoiding Negative Dysphagia Outcomes
Dennis C. Tanner, PhD; William R. Culbertson, PhD (April 23, 2014)
- Electronic Health Record: Driving Evidence-Based Catheter-Associated Urinary Tract Infections (CAUTI) Care Practices
Lois M. Welden, MSN, RN (August 6, 2013)
- Elder Mistreatment and the Elder Justice Act
Nancy L. Falk, PhD, MBA, RN; Judith Baigis, PhD, RN, FAAN; Catharine Kopac, PhD, DMin, RN, CGNP (August 14, 2012)
- Promoting Safe Use of Medical Devices
Sonia C. Swayze, RN, MA; Suzanne E. Rich, RN, MA, CT (October 17, 2011)
- The Professional Nursing Association’s Role in Patient Safety
Patricia A. Rowell, PhD, RN, CNP (September 30, 2003)
- Improving Quality and Patient Safety by Retaining Nursing Expertise
Karen S. Hill, DNP, RN, NEA-BC, FACHE (August 2, 2010)
- Vigilance: The Essence of Nursing
Geralyn Meyer, PhD, RN; Mary Ann Lavin, ScD, RN, FAAN (June 23, 2005)
- Measuring Fall Program Outcomes
Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN; Julia Neily, RN, MS, MPH; Mary Watson, MSN, ARNP, BC; Marilyn Wright, BSN, RN.C; Karen Strobel, RN, MSN (March 2, 2007)
- Survey of Advanced Practice Registered Nurses Disciplinary Action
Randall Hudspeth, MS, APRN-CNS/NP (April 2, 2007)
- Patient Safety: A Shared Responsibility
Karen A. Ballard, MA, RN (September 30, 2003)
- Health Systems’ Accountability for Patient Safety
David Keepnews, PhD, JD, RN, FAAN; Pamela H. Mitchell, PhD, RN, FAAN (September 30, 2003)