News :Nurses Are Key to Creating a Culture of Patient Safety
Posted on Thursday, July 24, 2008
Medical errors result in as many as 98,000 American deaths each year, according to the National Academy of Sciences’ Institute of Medicine. Another 1.5 million patients are harmed by medication errors. One in five Americans report that they or a family member have experienced some kind of medical error. The annual cost of preventable patient injury resulting from medical mistakes is more than $30 billion.
Doctors, nurses, and healthcare workers are in the business of saving lives, but our medical system is complex. Humans are not infallible and errors occur. Errors can be caused by changes in treatment standards, drug names that sound alike, bad handwriting on a chart or prescription, a missed or missing decimal point, an identity mix-up, poor communication, or healthcare worker fatigue, often caused by increased workloads resulting from inadequate staffing levels.
“Medical errors most often result from a complex interplay of multiple factors,” explains Dr. Lucian Leape of the Harvard School of Public Health, who is recognized as the father of the patient safety movement in the U.S. “Only rarely are they due to the carelessness or misconduct of single individuals.”
Most healthcare organizations are working to create cultures of safety to prevent medical errors and improve patient safety. The old “blame and train” mentality that punishes individuals for errors is being replaced by a more effective management model that recognizes that errors usually occur as the result of ineffective, improperly designed, or flawed systems. Creating a culture of safety recognizes the necessity of redesigning medical systems to promote a safe patient environment.
Nurses and other healthcare workers intimately involved in the daily care of patients will always carry the burden of safeguarding patient safety. America’s 2.8 million licensed nurses and 2.3 million nursing assistants represent 54 percent of all U.S. healthcare workers. In caring for patients and interacting with their families, nurses acquire a depth of knowledge about their patients that is unavailable to other providers on the medical team. Their repeated interaction with patients uniquely places them in a position to provide the constant surveillance necessary to identify and prevent potential medical errors.
University of Pennsylvania nursing expert Linda Aiken called nurses “the early warning and early intervention system” in hospitals and other healthcare institutions. Through their vigilance, nurses “are responsible for intercepting 86 percent of all errors made by physicians, pharmacists, and others involved in providing medications prior to the medication being administered.”
Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality, stated at a 2006 conference of the Nurse Alliance of Service Employees International Union that “nurses are the best advocates that a patient can have in a hospital,” adding that nurse advocacy is critical to improving the safety and quality of patient care.
Tips for preventing medical errors
Nurses and other healthcare workers must serve as advocates for their patients, particularly for those too ill to advocate for themselves. Nurses are the front line of defense in the battle to prevent medical errors. Follow these tips for preventing medical errors:
• Accept accountability for your actions. If you make an error, report it. If you suspect an error on the part of another person, speak up. If you feel fatigue or stress is at any time impairing your ability to safely perform your job, seek immediate help from your supervisor. Silence can have disastrous results for your patient.
• Practice prevention. Do not rely on memory; always check the chart for care instructions and updates. If you are unclear on care instructions or medications, or if you can’t clearly read a chart or prescription, obtain clarification before taking action.
• Medical care is a team experience. Share your knowledge and insights with the team. Learn from the successes and mistakes of others.
• Take time to be safe. Each year two million Americans contract infections during hospital stays and nearly 100,000 die, making hospital infections the sixth leading cause of death in the U.S. Be scrupulous in your practice of hygiene – particularly hand hygiene – and follow all safety procedures.
• Encourage self-advocacy. Encourage your patients to create and maintain a personal health record and share it with their medical providers. Recommend that they carry a Universal Medication Card that lists all of the medications they take. Invite patients to ask questions about their health and care and provide answers and resources.
What will the future bring?
Efforts to create a culture of patient safety have resulted in several initiatives to improve the safety, quality, efficiency, and effectiveness of healthcare in America. Health Information Technology (HIT) is slowly revolutionizing U.S. healthcare. In 2004, President Bush announced a federal plan to digitize and connect most Americans’ medical records by 2014, saying, “By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care.”
Concerns about patient privacy rights and sensitive information getting into the wrong hands have been raised in Congress, but the medical community is gradually embracing the idea. “HIT has huge potential, and in the next several years it will become much more universal than it is now,” prophesized Harvard Medical School professor Dr. Don Goldmann, Vice President of the nonprofit Institute for Healthcare Improvement. “But we shouldn’t underestimate the complexity and cost.”
HIT envisions fully-computerized, integrated medical records that would allow doctors, pharmacists, and medical staff to instantly access and search complete records from any location at any time, day or night. A complex trigger system would alert providers to potential drug interactions, allergies, dosing errors, even the latest medical research. Computerized medical records might not prevent every medical error, but they can provide an extra layer of protection against mistakes. Some hospitals have already taken a step toward this goal. Boston’s Brigham and Women’s Hospital initiated an advanced electronic records system in 1993, reporting an 88 percent drop in serious medication errors in first two years of use. Some hospitals have implemented barcode systems that link provider ID badges, patient bracelets, and medications. The systems use computers to track medications and alert staff to potential errors, hazardous drug interactions, and overdoses.
Sources:
1 Centers for Disease Control, National Practitioner Bank, National Academy of Sciences’ Institute of Medicine
2 The Commonwealth Fund Study, 2002; corroborative figures from the Agency for Healthcare Research and Quality, 2008
3Agency for Healthcare Research and Quality, 2008