Patient Safety and Nursing Care
What Is Patient Safety
Past efforts to reduce costs and streamline the delivery of health
care have led to significant changes, not always with a positive effect.
The
Institute of Medicine’s (IOM) report, To Err is Human, which spotlighted the
problem of patient safety, reported that tens of thousands of Americans die
each year as a result of human error in the delivery of health care (Institute
of Medicine , 2000).
The second report in this series described broader quality
issues and defined six aims: These included that care should be
(1) safe
(2)
effective
(3) patient-centered
(4) timely
(5) efficient
(6) equitable
(Institute of Medicine, 2001)
The most recent report found that nursing is
inseparably linked to patient safety, emphasizing that poor working conditions
for nurses and inadequate nurse staffing levels threaten patient safety and
increase the risk of errors (Institute of Medicine, 2003).
Improvement in Safety
To improve patient safety, common definitions should be used and it
should be understood that not all adverse events are patient safety problems.
Essentially, patient safety applies to initiatives designed to prevent adverse
outcomes resulting from errors and near misses.
Near misses are of interest
because of the high probability of the event causing harm to the patient. Unfortunately,
many adverse events and near misses are related to low nurse staffing levels or
unskilled and inexperienced clinicians.
Responsibilities of Health Care Leaders and Managers
Health care leaders and managers should strive to create nursing
work environments that are conducive to patient safety. To do this,
evidence-based management (EBM) strategies are suggested.
Most clinicians are
now familiar with the notion of evidence-based practice, defined as the
conscious. Explicit, and judicious integration of current best evidence to
inform clinical decision making.
However, EBM is a fairly new term and
framework (Sacket et al., 1996). EBM implies that managers, like clinical
practitioners, search for, critically appraise, and apply empirical evidence
from management research in their practice.
Currently, both managers and
clinicians have little research-based evidence to apply and are often not
experienced in the use of such evidence.
Transactional Leaders and Transformational Leaders
In a seminal study on leadership, transactional leaders were
differentiated from the more potent transformational leaders (Burns, J., 1978).
Transactional leadership typifies most leader follower relationships; it
involves a “you scratch my back, I’ll scratch yours” exchange.
In contrast,
transformational leadership occurs when leaders engage with their followers in
jointly held goals. This leadership approach is recommended because it
transforms all workers-both managers and staff in the pursuit of the higher
collective purpose of patient safety and quality care.
Evidence Base Findings
An emerging evidence base is finding a strong correlation between
higher staffing levels and lower occurrence of adverse events.
In a study of
589 hospitals in 10 states, the registered nurse (RN) staffing level was found
to be inversely related to urinary tract infections (UTI) and pneumonia after
major surgery (p < .0001) (Kovner & Gergen, 1998).
In another study of
799 hospitals from 11 states, researchers found UTI and pneumonia to have a
consistently strong inverse relationship with nurse staffing ratios (Needleman,
Buerhaus, Mattke , Stewart, &Zelevinski , 2001).
Staffing Level
A line of research with a broader focus than staffing levels is the
investigations involving Magnet hospitals (ie, hospitals that attract nurses,
hence the term Magnet).
When Magnet hospitals were matched with control
hospitals, controlling for case mix, Aiken and colleagues observed a Medicare
mortality rate that was lower by 4.6 per 1,000 discharges (95% confidence
interval 0.9 to 9.4) (Aiken, Smith, & Lake, 1994 ).
However, besides the
attention of Magnet status, specifications were not identified. Magnet
hospitals are known for higher nurse-to-patient ratios, lower staff turnover
rates, and higher rates of nursing satisfaction.
Nursing Position
Nurses are in the position of being “at the sharp end” of health
care interventions by being the patient’s advocate, providing care that may
result in an error, or witnessing the error(s) of other clinicians.
Accidents,
errors, and adverse outcomes result from a chain of events involving human
decisions and actions associated with active failures and latent failures. Many
of these failures are associated with individual performance that is impaired
by stress, distractions/interruptions, and fatigue.
Limitation on Care Delivery Needs
Care delivery needs to be redesigned respecting human limitations,
particularly the debilitating effects of stress and fatigue on performance
(Norman, 2002). Research continues to confirm that clinicians with the
appropriate skill, experience, and workload are less likely to make patient
safety errors.
Yet one of the barriers to improving patient safety, considering
the level and types of interactions among clinicians and components within
health care, is the ability to recognize and correct errors (Kohn, Corrigan,
& Don- aldson , 2000).
Organizational Cultural Impact
There is increasing consensus that the organizational culture
impacts patient safety and the quality of care (Gershon, Stone, Bakken , &
Larson, 2004). Important aspects of safety cultures include communication,
non-hierarchical decision making, constrained improvisation, training, and
rewards and incentives (IOM, 2003a).
Organisational and Individual Commitment
Organizational and individual commitment to improving patient
safety requires effective leadership and proactive interventions. Patient
safety improvements need to draw from qualitative and quantitative research
describing work processes and responsibilities, methods to improve performance
respecting human limitations, and designs of patient safety supportive
communication and team approaches to health care delivery.