PATIENT SAFETY:
- Defining Patient Safety and Quality Care:
Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.”1 Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world.2 Harteloh3 reviewed multiple conceptualizations of quality and concluded with a very abstract definition: “Quality [is] an optimal balance between possibilities realised and a framework of norms and values.” This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities).
Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”4 This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. Theses standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds—death, disease, disability, discomfort, and dissatisfaction5—rather than more positive components of quality.
The work of the American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs.6, 7 The latter indicators were outlined more fully by the National Quality Forum.8 Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators.
The most recent IOM work to identify the components of quality care for the 21st century is centered on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centered, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built.Patient Safety
A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient safety was defined by the IOM as “the prevention of harm to patients.”1 Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients.1, 10 The glossary at the AHRQ Patient Safety Network Web site expands upon the definition of prevention of harm: “freedom from accidental or preventable injuries produced by medical care.”11
Patient safety practices have been defined as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.”12 This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm. Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows:
Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
Use of perioperative beta-blockers in appropriate patients to prevent perioperative. morbidity and mortality
Use of maximum sterile barriers while placing central intravenous catheters to prevent infections. Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections.
Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia Use of pressure-relieving bedding materials to prevent pressure ulcers
Use of real-time ultrasound guidance during central line insertion to prevent complications.
Patient self-management for warfarin (Coumadin®) to achieve appropriate outpatient anticoagulation and prevent complications Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.
Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research.
Quality Forum attempted to bring clarity and concreteness to the multiple definitions with its report, Standardizing a Patient Safety Taxonomy.13 This framework and taxonomy defines harm as the impact and severity of a process of care failure: “temporary or permanent impairment of physical or psychological body functions or structure.” Note that this classification refers to the negative outcomes of lack of patient safety; it is not a positive classification of what promotes safety and prevents harm. The origins of the patient safety .
What Is It Going To Take To Improve the Safety and Quality of Health Care?
Changes in health care work environments are needed to realize quality and safety improvements. Because errors, particularly adverse events, are caused by the cumulative effects of smaller errors within organizational structures and processes of care, focusing on the systemic approach of change focuses on those factors in the chain of events leading to errors and adverse events.5, 99 From a systems approach, avoidable errors are targeted through key strategies such as effective teamwork and communication, institutionalizing a culture of safety, providing patient-centered care, and using evidence-based practice with the objective of managing uncertainty and the goal of improvement.
The Right Work Environment
The major focus of the IOM’s report, Keeping Patients Safe: Transforming the Work Environment of Nurses,1 was to emphasize the dominant role of the work environment within health care organizations and the importance of the work environment in which nurses provide care to patients. Research reviewed by the IOM committee reported that nurses were dissatisfied with their work and wanted better working conditions and greater autonomy in meeting the needs of patients. The significance of these and many other findings led to the committee recommending significant changes in the way all health care organizations were structured, including “(1) management and leadership, (2) workforce deployment, (3) work processes, and (4) organizational cultures”1 (p. 48). After the release of that report, the American Association of Critical-Care Nurses (AACN) expanded upon these concepts and put forth the following standards for establishing and sustaining healthy work environments: (1) effective, skilled communication; (2) true collaboration that is fostered continuously; (3) effective decision making that values the contributions of nurses; (4) appropriate staffing that matches skill mix to patient needs; (5) meaningful recognition of the value of all staff; and (6) authentic leadership where nurse leaders are committed to a healthy work environment and engage everyone.100 To achieve these standards, many organizations will need to significantly change the work environment for nurses.
The nursing “practice environment” is defined by organizational characteristics that can either facilitate or constrain professional nursing practice.101 Changes to the nurses’ work environment need to focus on enabling and supporting nurses to provide high-quality and safe care.102 To do so, there needs to be significant changes in the way health care is organized that also address nursing workforce resources, training, and competencies. Researchers have found that nurses may experience greater professional fulfillment when strategies are implemented that promote autonomous practice environments, provide financial incentives, and recognize professional status.103 Whether because of unequal distribution of nurses or expected nursing workforce shortages with the aging of practicing nurses and faculty,104, 105 staffing shortages increase a nurse’s stress, increases their workload, and can adversely impact patient outcomes. More important, clinicians in practice will need new skills and empowerment to work effectively with colleagues within their work environments. Nurses also need to possess certain competencies that reflect the nature of nursing in improving patient and systems outcomes, including evidence-based practice, patient-centered care, teamwork and collaboration, safety, quality improvement, and informatics.
Opportunity, power, and the composition of the workforce within organizations influence what nurses are able to do and how they are able to use resources to meet patients’ needs. Lashinger and colleagues76, 107–109 have found that the empowerment of staff nurses increased with greater responsibilities associated with job advancements and was related to the nurses’ commitment to the organization, burnout, job autonomy, their ability to participate in organizational decision making, as well as job strain and work satisfaction.110 Because work environment factors influence the perceptions of nurses as being supported in their work, having a sense of accomplishment,111 and being satisfied with their work, it is important to empower staff to manage their own work, collaborate in effective teams,112 and practice nursing in “optimal” conditions.113 Professional empowerment in the workplace is derived from competence and interactions with colleagues and other clinicians within organizations—and with patients—as well as by demonstrating knowledge and gaining credibility.114 For nurses, structural empowerment can have a direct effect on their experience of providing care in their work environment.115 Models of care, such as a professional practice model, not only can improve work satisfaction, but they can facilitate patient and nursing outcomes.
Teamwork and Collaboration:
It is nonsensical to believe that one group or organization or person can improve the quality and safety of health care in this Nation. In that patient safety is inextricably linked with communication and teamwork,6 there is a significant need to improve teamwork and communication.139, 140 Teamwork and collaboration has been emphasized by the Joint Commission. The Joint Commission has found communication failures to be the primary root cause of more than 60 percent of sentinel events reported to the Joint Commission.141 Ineffective communication or problems with communication can lead to misunderstandings, loss of information, and the wrong information.142 There are many strategies to improve interdisciplinary collaboration (e.g., physician and nurse),140, 143 including using multidisciplinary teams as a standard for care processes.
Interprofessional and intraprofessional collaboration, through multidisciplinary teams, is important in the right work environments. Skills for teamwork are considered nontechnical and include leadership, mutual performance monitoring, adaptability, and flexibility.144 Teamwork and interdisciplinary collaboration139 have the potential to mitigate error and increase system resilience to error.145 Clinicians working in teams will make fewer errors when they work well together, use well-planned and standardized processes, know team members’ and their own responsibilities, and constantly monitor team members’ performance to prevent errors before they could cause harm.6, 146, 147 Teams can be effective when members monitor each other’s performance, provide assistance and feedback when needed,147 and when they distribute workloads and shift responsibilities to others when necessary.144
The importance of training members to work effectively in multidisciplinary teams to achieve high reliability in patient (e.g., no adverse events) and staff outcomes (e.g., satisfaction working with team members and improved communication)145, 148–151 was found to be especially significant when team members were given formal training to improve behaviors.145 Resources such as AHRQ’s TeamSTEPPS™ (visit http://www.ahrq.gov/qual/teamstepps) can provide teams with the opportunities the members need to improve the quality and safety of health care. TeamSTEPPS™ is an evidence-based teamwork system that teams can use to improve communication and other essential teamwork skills.
In a comparison of medicine to aviation, physicians were found to be significantly more supportive of hierarchical models of practice, where junior physicians would not question their seniors.152 Hierarchical structures have been found to have an adverse influence on communication among team members and patient outcomes.157, 158 Nursing’s participation in teams is further limited under a hierarchical, mechanistic structure when nurses focus on tasks.159 Other barriers that have been found to inhibit the effectiveness of nurses in teams were their perceptions of teamwork, having different teamwork skills, and the dominance of physicians in team interactions.160 When physicians view hospitals as a “platform[s] for their work and do not see themselves as being part of [the] larger organization”1 (p. 144), physicians may not only thwart the work of nurses, but the organization’s efforts to improve the quality and safety of care. When anyone within organizations exhibit intimidating or disruptive behaviors and when there are inappropriate hierarchies, breakdowns in teamwork, and loss of trust, decreased morale and turnover are expected among staff; patients can expect to be harmed and will likely seek care elsewhere.
The work environment, communication and collaboration among clinicians, and decisionmaking are also linked to leadership and management within health care organizations.164–166 Some authors have argued that performance of organizations and the use of evidence in practice were factors dependent upon leadership, particularly among middle/unit-based clinical management.167–169 The personality and attitudes of leaders has been shown to have an impact on safety170, 171 and on perceptions about how safety is managed.172 Visible, supportive, and transformational nursing leadership to address nursing practice and work environment issues is critical as is nursing and medical leadership to ensure that the work environment supports caregivers and fosters collaborative partnerships. However, giving encouragement is not generally stated as a high-priority role of health care supervisors. Traditionally, technical skills and productivity on the job were aspects that received the supervisor's primary focus. However, there is a growing appreciation that encouragement is a transformational leadership technique that is related to productivity on the job and to quality work. Use of encouragement is a leadership technique that fits in today's people-oriented work climate.