There are growing concerns in the public and political arenas regarding patient safety. Among these concerns are medical errors. Medical errors are preventable occurrences that threaten every patient’s safety in all medical facilities including nursing home care and home health care. HospitalSafetyScore.org is website dedicated to researching hospital safety and keeping the public informed of its findings. It is operated by Leapfrog, an independent organization, that advocates for patient safety. Their website indicates that “as many as 440,000 Americans are dying annually from preventable hospital errors (The Leapfrog Group, 2013).” That is an astounding number of people being senselessly buried each year due to unnecessary and avoidable circumstances.
This week’s video also addresses medical errors indicating that health care should be addressed in a multidisciplinary, collaborative fashion. Now more than ever organizations should expect more from their health care employees because Medicare (and other government insurance policies) will not pay for medical errors and avoidable circumstances (Laureate Education, 2009). To address medical errors and financial concerns, health care organizations are going to shift their focus onto prevention and control of medical errors and education of their health care employees.
In response the growing concern of medical errors, the Institute for Healthcare Improvement (IHI) introduced the 5 Million Lives campaign in December of 2006 and it continued until December of 2008. “IHI and its partners in the Campaign encouraged hospitals and other health care providers to take the following steps to reduce harm and deaths:
• Prevent Pressure Ulcers by reliably using science-based guidelines for prevention of this serious and common complication
• Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infection through basic changes in infection control processes throughout the hospital
• Prevent Harm from High-Alert Medications starting with a focus on anticoagulants, sedatives, narcotics, and insulin
• Reduce Surgical Complications by reliably implementing the changes in care recommended by the Surgical Care Improvement Project (SCIP)
• Deliver Reliable, Evidence-Based Care for Congestive Heart Failure to reduce readmission
• Get Boards on Board by defining and spreading new and leveraged processes for hospitals Boards of Directors, so that they can become far more effective in accelerating the improvement of care (Institute for Healthcare Improvement, N.D.)”
This campaign and other public initiatives are very important to medical communities in an effort to gain the public’s trust and seek ways to make improvements.
Nursing Responsibilities to Medical Errors and Patient Safety
Nurses can play a significant role in reducing medical errors in several ways. First and most importantly, nurses should always be advocates for their patients. If the patient or the nurse has a concern, it should always be addressed as a group effort. Other nurses, clinical specialists, and primary care providers should be made aware of concerns and addressed in “two heads are better than one” atmosphere. Second, nurses should be aware of and use the best evidence-based practices for patient care. New techniques to maintain sterility, new medication administration practices, and proper use of patient safety equipment are a few that come to mind. Third, nurses need to be involved in the development and implementation of protocols and practice standards (Laureate Education, 2009). Involvement in these types of activities builds knowledge and understanding in a collaborative environment.
As a nation, we are far from where we need to be to properly address patient safety. It is everyone’s responsibility to keep and maintain standards in all medical environments. With teamwork, research, and education, great strides can be made.
Discussion 2: Dianne
Patient safety is at the forefront of our healthcare system. We often think of patient safety as only influencing outcomes for patients. In reality, a lack of patient safety has institutional implications such as litigious action, decreased reimbursement, negative PR and potential loss of accreditation. In this discussion, I will weave relevant insights from our course materials with my firsthand experiences as a nurse in a perioperative hospital setting.
Back in 2000, it was estimated that 98,000 people die every year from healthcare errors. (Mason, 2016). This number has grown exponentially since then. In a 2015 report by Healthcare IT news, we learn that an estimated 400,000 people now die each year from preventable medical errors. (McCann, 2014). Mason et. al. call out a range from 220,000 to 440,000 deaths each year due to patient safety challenges. (Mason, 2016). There are a number of contributing factors that have driven this rise in mortality due to safety issues. For example, in the Laureate video found in our course resources, we learn that “failure is due to poor process 85% of the time.” (Laureate Education, 2009). Other core barriers include lack of the establishment of safety as an organizational priority, poor teamwork, little patient involvement, and low openness/transparency, and accountability on the institutional side. (Lamb, 2003).
Despite the perceived failures captured above, we have seen some successes and best practices in the past decade with regard to patient safety. For example, in a 2012 National Healthcare Quality Report (NHQR), 60% of all measures demonstrated improvement with a greater proportion of the improvement occurring in the hospital setting. (AHRQ, 2013). Best practice programs are grounded in critical success factors such as identifying patients correctly, using medicine safely and avoiding surgical errors. (Kreimer, 2010). The perioperative care environment presents unique challenges in regards to patient safety because of a myriad of different care providers, multiple complex procedures and the fast-paced, critical care environment. I work in a very busy cardiac cath lab. We have adopted some of the best practices provided above in an attempt to drive positive patient outcomes. One of these practices is the procedural Time Out. Time Out, where we state the correct patient, procedure, physician and voice any questions or concerns immediately prior to the start of the case, was not routinely done in the cath lab. We have made this a standard of care so that all care providers are on the same page and communication is seamless so as to provide optimal care and prevent errors. Another best practice is the safe administration of medications. We are often running at a frantic pace in our unit. We have patients who come in having a heart attack and things can get very intense very quickly. After experiencing some medication related errors, we adopted the process of having two nurses verify certain medications that are paramount to the success of our procedures. Since this practice has been utilized, we have not had a repeat of the errors that occurred.
In conclusion, patient safety must be top of mind for the nursing staff, risk management, hospital administration, patients and family caregivers. Patient safety is not just an in-service or a policy. It is a culture that should be instilled through staff development activities, sharing of patient safety data and open dialogue regarding best practices and continuous quality improvement.
1.) Write a one paragraph response to this question: As a nurse leader what are some ways in which nursing leaders ensure patient safety?
2.) Write a one paragraph response to each discussion provided in the uploaded files. Respond to each postings in one or more of the following ways:
• Ask a probing question.
• Expand on the colleague’s posting. In addition to, but not in place of the above, you may:
• Offer and support an opinion.
• Validate an idea with your own experience.
• Make a suggestion or comment which guides or facilitates the discussion.