Patient Safety and Quality Care

Jessica Jean-LouisUniversity of South FloridaPatient Safety and Quality Care

IntroductionThe Institute of Medicine (IOM) released To Err Is Human1Issues of preventable medical errorsEstimated 44,000 to 98,000 patient mortalitiesCost of medical errors: 7 billion to 29 billion per yearReducing preventable medical errors becomes a movement in health care

The Patient Safety Movement was born after the Institute of Medicine (IOM) released a report entitled To Err Is Human. The report received national attention by highlighting the issues of preventable medical errors in the health care system. It is estimated that in 1997, between 44,00 and 98,000 patients died in health care facilities as a result of preventable medical errorsThe cost of medical errors is estimated to cost the nation 7 billion and 29 billion per year if you factor in health care costs, lost income, lost household productivity, and disability(1) Levy2

DefinitionPatient Safety1The prevention of harm to patients Quality Care2the degree to which health services for individuals and populations increased the likelihood of desired health outcomes and are consistent with current professional knowledge

IOM defines Patient safety as the prevention of harm to patients (1)IOM Definition of Quality is the degree to which health services for individuals and populations increased the likelihood of desired health outcomes and are consistent with current professional knowledge (2)Based on The delivery of careError preventionsCreating a systems that learns from the errors that do occurBuilding a culture that of safety that involves health care professionals, organizations, and patientsLevy (1)

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Types of Safety errorsLatent2

Active

Organizational

Technical

Latent failureRemoved from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resourcesActiveInvolves direct contact with the patientOrganizational Systemindirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factorsTechnical FailuresIndirect failure of facilities or external resources

(Mitchell)4

Iom 21st Century concepts of quality carePhase 1 and 22Broader quality issuesSix Aims10 rules for care delivery redesign

Phase 3Reforming Health Professions EducationPrevention of Medication ErrorsEtc.

After the Err is Human report, the IOM released a report called Crossing the Quality Chasm: A New Health System for the 21st Century (2)The first phases of the report were recommendations of more broader quality issues Six aimsCare should be safe, effective, patient-centered, timely, efficient and equitable10 rules for care delivery redesignThe most recent phase is focusing on creating a more patient responsive 21st century health system by involving various stakeholders like foundations, government agencies, and quality organizations. The purpose is to reform the health care system at the environmental levels, level of the health care organizations, and the interface level between clinicians and patientsFostering rapid Advances in Health CareRedesigning Care Delivery Furthering Measurement and Informed PurchasingReforming Health Professions EducationEncouraging Information Technology ImplementationPrevention of Medication ErrorsEtc.

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Significance to nursing professionThe past: Florence Nightingale3Reduced British Troop Mortality in 1855The PresentNarrow aspects of Patient Carei.e Medication errors,Broader aspects of Patient CareStaffingCommunication Link

Florence Nightingale reduced mortality among British troops in 1855 by improving organizational and hygienic practices.

Nurses are involved in patient care in a more broader scope than often perceived.Narrow aspects of patient careavoiding medication errors preventing patient fallsPreventing hospital acquired infectionsBroader aspectsCoordination of care through better staffingA greater percentage of registered nurses to other nursing staff lowers the risk of complications and mortalityPrime communication link in a health care settingRoot cause analysis indications that breakdowns in communication leads to patient harm Surveillance to reduce adverse outcomes

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Significance to studentsCritical ThinkingLearning OpportunitiesSimulationQuality and Safety Education for Nurses (QSEN)4Importance of patient safety

Nursing students are expected to develop critical thinking skills that will equip them with problem solving techniques that promotes safety teaching (4)National League for NursingPromotes simulation in Nursing education to reduce medical errorsQuality and Safety Education for Nurses (QSEN) initiative places emphasis on teaching and the importance of patient safety 7

ConclusionReviewPatient Safety as a MovementPromote patient safety by preventing and analyzing different types of errorsmultifaceted approach of IOMs 21st century agendaNurses involvement as communication links and coordinators Learning opportunities for students

Personal Application

As a new graduate I plan on putting emphasis on doing my part in promoting safer practices. I also plan on using the recommendations from the institute of medicine to encourage a culture that prevents medical error. Reporting near misses, is something I plan on taking very seriously so that my unit will be encouraged to do root cause analysis and create new policies that will minimize errors. Patient safety is a movement and I plan to be active in it throughout my career and I hope to influence others to do the same. 8

ReferencesLevy, F., Mareniss, D., Iacovelli, C., & Howard, J. (2010). The patient safety and quality improvement act of 2005: Preventing error and promoting patient safety. The Journal of Legal Medicine, 31(4), 397-422. Mitchell, P. (2008). Defining patient safety and quality care. In R. Hughes (Ed.), Hughes RG, editor. patient safety and quality: An evidence-based handbook for nurses (). Rockville, MD: Agency for Healthcare Research and Quality. National Academy of Sciences. (2013). Crossing the quality chasm: The IOM health care quality initiative. Retrieved from https://www.nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx National League for Nursing. (2015). A vision for teaching with simulation. ().

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