By Glenna Murdock, RN, contributor
March 18, 2011 - When medical errors and patient safety were revealed as a national problem by the Institute of Medicine’s 1999 report, To Err is Human—which found that nearly 100,000 people die unnecessarily in the United States each year due to preventable medical errors—it led to a new focus in health care that has been dubbed the patient safety movement.
Since that time, error prevention and increased safety protocols have become a key topic in the health care reform debate, spawning new requirements and regulations. Providers have had to conduct internal assessments to identify safety shortcomings, then develop solutions to rectify the problems.
A single, off-the-shelf solution has yet to be found, but many health care experts agree that nurses can and should be a key part of a multifaceted solution.
Multiple elements are involved in creating a culture of safety within a facility, according to Dana Wade, MSN, RN, senior director of nursing quality at the Cleveland Clinic in Ohio (The Clinic).
“There are many components that must come together,” she said. “There must be support from management and leadership and policies and standards need to be in place. Personnel competency is essential, as is communication among the health care team.”
Staff education is ongoing and there is an emphasis on patient safety during the orientation of all new employees at The Clinic.
“In addition to classroom orientation, new employees are given hands-on experience in procedures such as how to correctly tie hand restraints,” said Monica Weber, MSN, RN, patient safety officer at The Clinic. “They are also assigned a preceptor who advises and guides them. Some of the instruction may seem redundant, but repetition increases the understanding of what they’ve read in the literature.”
There is evidence that the reporting of errors is a key factor in identifying and rectifying safety concerns, yet most are not reported due to the punitive attitudes often aimed at the person who has made the mistake (McFadden, et. al., 2006). The patient safety movement supports a shift away from the “culture of blame” that views errors as the fault of a specific individual and promotes the notion that errors often occur as a result of flawed systems within a facility. Their prevention, therefore, is a shared responsibility of all the staff.
Weber agrees that the reporting of errors is a major step in reducing mistakes and risks.
“We encourage our staff to report errors with the understanding that they will be supported, not punished,” commented Weber, who is a member of the Clinic’s quality committee. “When nurses feel supported they are far more likely to report errors and sentinel events. Reporting can be done online and there is always a ‘thank you’ sent in response. All reports are reviewed and reported to the quality committee to decide what should be done to put prevention in place.”
Nurses spend more time with patients than others on the health care team and are, therefore, on the frontlines for assuring patient safety and identifying potential risks.
“Nurses are attuned to patient safety and very aware of such things as falls, medication errors and pressure ulcers,” Wade stated. “The Clinic’s safety policies, systems and training rely on their opinions and insights.”
Effective communication cannot be overemphasized according to both Wade and Weber.
“The transference of care from one shift to the next is vital to the safety of our patients,” Wade stated. “Report is done at the bedside. The patient and the family, if they are present, hear what is planned for the patient that day and they have the opportunity to interject concerns and ask questions. Hourly rounds and anticipating the needs of the patient can prevent falls, for instance, by suggesting she help the patient to the bathroom while she is there, rather than risking the patient’s possible attempt to get there on his own at a later time.”
“Interdisciplinary rounding is invaluable,” Weber said. “The care team, which could include a pharmacist, a social worker and others, in addition to the nurse and physician, makes certain that they are in agreement regarding the patient’s care and that they are speaking in one voice. Yes, it might, at times require extra staffing but team rounding is necessary for optimum patient safety. One discipline can’t do it alone and hospitals can’t afford not to do it.”
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