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Patient safety and quality care
- 1. J E S S I C A J E A N - L O U I S U N I V E R S I T Y O F S O U T H F L O R I D A PATIENT SAFETY AND QUALITY CARE
- 2. INTRODUCTION • The Institute of Medicine (IOM) released “To Err Is Human”1 • Issues of preventable medical errors • Estimated 44,000 to 98,000 patient mortalities • Cost of medical errors: 7 billion to 29 billion per year • Reducing preventable medical errors becomes a movement in health care
- 3. DEFINITION • Patient Safety1 • ‘The prevention of harm to patients” • Quality Care2 • “the degree to which health services for individuals and populations increased the likelihood of desired health outcomes and are consistent with current professional knowledge”
- 4. TYPES OF SAFETY ERRORS • Latent2 • Active • Organizational • Technical
- 5. IOM 21ST CENTURY CONCEPTS OF QUALITY CARE • Phase 1 and 22 • Broader quality issues • Six Aims • 10 rules for care delivery redesign • Phase 3 • Reforming Health Professions Education • Prevention of Medication Errors • Etc.
- 6. SIGNIFICANCE TO NURSING PROFESSION • The past: Florence Nightingale3 • Reduced British Troop Mortality in 1855 • The Present • Narrow aspects of Patient Care • i.e Medication errors, • Broader aspects of Patient Care • Staffing • Communication Link
- 7. SIGNIFICANCE TO STUDENTS • Critical Thinking • Learning Opportunities • Simulation • Quality and Safety Education for Nurses (QSEN)4 • Importance of patient safety
- 8. CONCLUSION • Review • Patient Safety as a Movement • Promote patient safety by preventing and analyzing different types of errors • multifaceted approach of IOM’s 21st century agenda • Nurses involvement as communication links and coordinators • Learning opportunities for students • Personal Application
- 9. REFERENCES 1. Levy, 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. 2. 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. 3. National Academy of Sciences. (2013). Crossing the quality chasm: The IOM health care quality initiative. Retrieved from https://www.nationalacademies.org/hmd/Global/News%20Announ cements/Crossing-the-Quality-Chasm-The-IOM-Health-Care- Quality-Initiative.aspx 4. National League for Nursing. (2015). A vision for teaching with simulation. ().
Editor's Notes
- 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 errors The 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) Levy
- 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 care Error preventions Creating a systems that learns from the errors that do occur Building a culture that of safety that involves health care professionals, organizations, and patients Levy (1)
- Latent failure “Removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources” Active Involves direct contact with the patient Organizational System “indirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors” Technical Failures “Indirect failure of facilities or external resources” (Mitchell)
- 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 aims Care should be safe, effective, patient-centered, timely, efficient and equitable 10 rules for care delivery redesign The 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 patients Fostering rapid Advances in Health Care Redesigning Care Delivery Furthering Measurement and Informed Purchasing Reforming Health Professions Education Encouraging Information Technology Implementation Prevention of Medication Errors Etc.
- 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 care avoiding medication errors preventing patient falls Preventing hospital acquired infections Broader aspects Coordination of care through better staffing A greater percentage of registered nurses to other nursing staff lowers the risk of complications and mortality Prime communication link in a health care setting Root –cause analysis indications that breakdowns in communication leads to patient harm Surveillance to reduce adverse outcomes
- 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 Nursing Promotes simulation in Nursing education to reduce medical errors Quality and Safety Education for Nurses (QSEN) initiative places emphasis on teaching and the importance of patient safety
- 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.