Karen A. Ballard, MA, RN
Patient safety is an essential and vital component of quality nursing care. However, the nation’s health care system is prone to errors, and can be detrimental to safe patient care, as a result of basic systems flaws. A variety of stakeholders (society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments and legislative bodies; professional associations; and accrediting agencies) are responsible for ensuring that patient care is safely delivered and that no harm occurs to patients. The responsibility of these stakeholders in addressing patient safety in the context of a nursing shortage is discussed, along with specific actions they have taken, and can continue to take, to promote safe care.
Citation: Ballard, K. (September 30, 2003). "Patient Safety: A Shared Responsibility". Online Journal of Issues in Nursing. Vol. 8 No. 3, Manuscript 4. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/PatientSafety.aspx
Key words: patient safety, health care errors, competency, patient outcomes, stakeholders, nursing shortage, ethics, lifelong learning, nursing standards, licensure, safety legislation, magnet hospitals
Patient Safety: A S2hared Responsibility
Patient safety is an essential and vital component of quality care. Yet health care providers face many challenges in today’s health care environment in trying to keep patients safe. This article will describe what a variety of individuals and groups have done, and what yet remains to be done, to promote safe care for all.
Error is said to occur when a planned sequence of mental or physical activities fails to achieve the intended outcome and when this failure cannot be attributed to some chance intervention or occurrence (Reason, 1990). In 1998, the President’s Advisory Committee on Consumer Protection and Quality in the Health Care Industry noted the following examples of errors in health care:
- 28% of adverse reactions to medications and 42% of life-threatening events in health care are preventable.
- 20% of patients in tertiary care medical centers experience adverse events.
- 10 to 30% of laboratory test results are inappropriately classified as normal (Cronenwett, 2002).
In 1999, the Institute of Medicine (IOM) described the nation’s health care system as fractured, prone to errors, and detrimental to safe patient care. It defined patient safety as freedom from accidental injury and further stated that ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur (IOM, 2000). IOM has also proposed six aims for improvement, and ten rules for redesign of the health care system, to make it safer. The six aims are:
- Safety – avoiding injuries to patients from the care that is intended to help them.
- Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit.
- Patient-centered – providing care that is respectful of and responsive to patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
- Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.
- Efficient – avoiding waste, including waste of equipment, supplies, ideas, and energy.
- Equitable – providing care that does not vary in quality because of personal characteristics such as gender, geographic location, and socioeconomic status (IOM, 2001).
One of the rules addesses safety as a "system property." This rule requires that patients be safe from injury caused by the care system and that more attention be made to preventing and mitigating errors (IOM, 2001).
The American Nurses Association (ANA) testified before an IOM committee that it is time to address the "unholy trinity" of patient injuries and health care errors, staffing shortages, and the looming nursing shortage. In this testimony, the impact upon nurses and patient safety of a workplace environment where nurses are stressed, fatigued, unable to use their critical thinking skills, predisposed to workplace related accidents, illnesses and injuries, and involved in incidents of medication errors and episodes of failure to rescue was discussed (ANA, 2002). ANA stated, "If the problems in the work environment are not addressed, nurses will not be able to sufficiently protect patients.…"(ANA, paragraph 12).
Who is Responsible for Ensuring Patient Safety?
Ultimately, all stakeholders are responsible to see that no harm occurs to patients. These stakeholders include: society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments including legislative bodies and regulators; professional associations; and accrediting agencies. This article will describe the responsibility these various stakeholders have assumed in addressing patient safety.
Society in General
It is difficult to address patient safety without acknowledging the current nursing shortage and its impact on practice. The Registered Nurse (RN) workforce is aging in the near term and shrinking in the longer term (Buerhaus, 2000). Nationwide there are 2.7 million nurses, with a reported 126,000 RN vacancies currently, and 400,000 RN vacancies estimated by 2020 (Murray, 2002). The nursing shortage endangers quality of care, places patients at risk, and could ultimately undermine the entire health care industry.
The nursing shortage endangers quality of care, places patients at risk, and could ultimately undermine the entire health care industry.
The nation has long endured many cyclical nursing shortages. It has been demonstrated from these past shortages that there are ways to alleviate the problem. Such interventions include: making changes in work hours; increasing financial bonuses for employment, wages, scholarships, and grants to support education; attracting "second careerists" into the profession; recruiting nurses from other countries; offering pay differentials and incentives for shift work and specialty nursing; making changes in practice modalities; and having facilities and administrators provide greater recognition of the contributions of the nursing staff.
Once again, another nursing shortage provides an opportunity to stop the cycle. But, one can question whether or not the motivation to change this cycle is present. The health care industry in this nation has long failed to appreciate that, in most health care settings, the main commodity that is being provided is nursing care, not medical care. This is not to diminish the value of the services provided by physicians, but to emphasize that often the majority of care required by patients is nursing care. The industry focuses instead on its convoluted struggles with managed care, cost cutting, changes in reimbursement, onerous regulations, increasing demands of technology, and burdensome documentation. What is needed is a workplace environment that successfully supports the delivery of nursing care to the satisfaction of both the nurses and the patients (Ballard, 2002).
The health care industry in this nation has long failed to appreciate that, in most health care settings, the main commodity that is being provided is nursing care...
It will be important for all of society to work to improve communication between direct care nurses and nursing management and administration, promote staffing flexibility and utilization of appropriate staffing formulas, discourage the use of mandatory overtime, provide adequate compensation, minimize hazards, promote workplace safety, and implement new technologies that automate non-valued tasks. Establishing the baccalaureate degree as entry-level into professional nursing practice will provide the knowledge needed to support increasingly complex nursing care. Also, considered necessary are increased technological support, reduction of unnecessary and duplicative paperwork, recruitment of men and ethnic and racial minorities, and improving the media and public’s image of nursing.
In the past, patients were often passive recipients of health care. Explanations of illnesses and conditions, diagnostic tests, surgical interventions, medications, and other treatments were often not clearly understood and/or questioned. Patients viewed their health care practitioners (physicians, nurses, pharmacists, therapists and other providers) as all knowing and, without question, competent and safe.
Over the past two decades this has changed. Today, most health care institutions and practitioners work to assure certain patient rights, such as the right to clear and appropriate education about illnesses and treatments, so as to support patient-informed choices. Patients often seek opportunities for additional opinions about appropriate interventions and designate health care proxies or direct end-of-life care through "living wills". They are increasingly active participants in their care. Patients often access information about health care problems through federal or state health information "hot lines", obtain educational materials produced by patient advocacy groups or organizations that address specific disease conditions, and retrieve health information on the Internet through such sites as: www.achoo.com, www.webMD.com and www.askanurse.com
Informed patients can do much to increase the safety of their care.
Informed patients can do much to increase the safety of their care. They can inquire about the credentials and competencies of the health care practitioners who are providing care and demand the provision of care by appropriately educated and licensed health care practitioners. The ANA’s campaign during the last nursing shortage, entitled "Every Patient Deserves a Nurse," helped patients understand the need to have Registered Nurses oversee their care. In addition, patients can request that health care facilities provide an "institutional report card" that describes such indices as outcomes of patient care for medical conditions and surgical interventions, medical error rates, nosocomial infection rates, RN to patient staffing ratios, availability of support personnel, morbidity and mortality rates, lengths of stays for patients with certain conditions, opportunities for pre-admission and discharge planning, and incidents of malpractice.
Nursing is a knowledge-based profession. The basis for the scientific practice of nursing includes nursing science; the biomedical, physical, economic, behavioral and social sciences; ethics; and philosophy. A nurse’s ability to be a critical thinker and to use this knowledge in the delivery of nursing care is essential to the well being and safety of those for whom nurses care (ANA, 2003b; Ballard, 2002).
Early in nursing history, Florence Nightingale advocated for safe care. She proposed that nurses through their practice had to put the patient in the best condition possible for nature to act upon the patient. In discussing contemporary nursing practice, ANA states that an essential feature of nursing is the provision of a caring relationship that facilitates health and healing (ANA, 2003a). In the Crimea, Nightingale conducted some of the earliest nursing studies on factors influencing the outcomes of patient care (Nightingale, 1859). It is important that nurses work to continue these traditions by strengthening the nurse-patient relationship and diligently using research findings so as to provide safe care for patients.
Laws, rules, and standards can also enhance safe care. Nurses are held accountable to follow the laws, regulations, and rules of the licensing authority and the standards and ethics of the profession as promulgated by the various nursing associations. These laws, rules, and standards include meeting educational requirements, maintaining competence in practice, and refraining from engaging in any acts of professional misconduct such as abusing a patient; practicing incompetently, fraudulently or while impaired; failing to document appropriately; revealing personally identifiable information about a patient; and inappropriately delegating professional acts (Ballard, 2002).
It is a nurse's professional responsibility to remain safe and competent by being a lifelong learner.
Nurses can also enhance safe care by serving as competent team leaders. The delivery of nursing care to patients is often a team effort in which RNs direct non-registered nurses. RNs must know the competencies, legal parameters, and tasks that can be performed by others, such as licensed practical nurses (LPNs) and unlicensed assistive personnel (UAPs). In 1990, the American Association of Critical Care Nurses (AACN) developed a list of six risk factors (potential for harm; condition/stability of the patient; complexity of the task; level of problem solving or innovation that might be needed; unpredictability of the outcome, and level of interaction required with the patient to successfully complete the task) for an RN to consider when evaluating whether an UAP could perform a certain task on a particular patient (AACN, 1990). RNs must provide the appropriate levels of direction and supervision when nursing care is being delivered by others so that the patient receives safe and competent care.
It is a nurse’s professional responsibility to remain safe and competent by being a lifelong learner. It is important to make informed choices about educational and clinical advancement and specialty certification. Educational choices can include continuing education courses or advanced degree programs. Clinical advancement can include becoming an advanced practice registered nurse (APRN) such as a nurse practitioner, clinical nurse specialist, nurse anesthetist, or nurse midwife, or deciding to specialize in a particular field of nursing through continuing education and/or clinical practice. Professional nurses can demonstrate proficiency and expertise in the practice of nursing by seeking certification in a clinical area (such as pediatrics, medical-surgical, or psychiatric-mental health) or in a specific role (such as administrator, informatics specialist, or staff development educator). Certification generally requires completion of an accredited educational program in the specialty, recommendations from professional colleagues, and passing a certification examination administered by the American Nurses Credentialing Center (ANCC) or a specialty nursing association.
Identifying potential risks and learning the proper terminology to identify and describe health care errors also promotes safe care. These activities will most likely occur in a non-punitive environment where nurses feel safe and supported when reporting errors or identifying needs. The impact of nurse staffing upon patient safety has been studied and demonstrated to be significant (Needleman & Buerhaus, 2003). Practice settings that support professional practice with a responsive nursing management, creative staffing and scheduling, adequate salaries and benefits, availability of clinical preceptors, adequate ancillary and technical support, and access to staff development and education provide the environment in which nurses can identify threats to patient safety (NYSNA, 1997).
Nursing Educators, Administrators and Researchers
Nurses in leadership positions also have a responsibility to promote safe care. Responsibilities and contributions by leaders, such as educators, administrators and researchers are described below.
Nursing educators. Nurses are prepared to competently and safely care for patients by completing a nursing program (diploma, associate degree, or baccalaureate) that is accredited by either the National League for Nursing (NLN) or the American Association of Colleges of Nursing (AACN) and successfully passing the national licensing examination (NCLEX) that is administered by the National Council of State Boards of Nursing (NCSBN). Nursing educators in all programs develop the critical thinking skills that are essential in the nurse’s ability to identify current or potential problems or risks that impact upon patient safety. They also teach the theoretical basis for nursing actions and the professional behaviors that provide nursing students with a foundation for preventing health care errors. Teaching content regarding risk factors for patient safety can also enhance the provision of safe patient care.
Nursing administrators. Nursing administrators and managers on a daily basis are systematically assessing the complex dynamics that influence the ability of nurses to practice in different health care settings. They are also developing policies and procedures to direct safe nursing practice and providing education of nurses regarding the interpretation and implementation of these policies and procedures. The availability of staff development departments is a critical factor in assisting the nurses to use these policies and procedures in delivering safe and competent care.
The availability of staff development departments is a critical factor...in delivering safe and competent care.
Nursing administrators and managers can also increase patient safety by fostering an environment in which nurses are in control of their own nursing practice. Hospitals that provide for professional autonomy for nurses and support control over nursing practice have better retention rates for nursing staff and better outcomes for patients (ANA, 2002). In a 1983 study by the American Academy of Nursing (AAN) McClure, Poulin, Sovie and Wandell identified the characteristics of hospitals that were able to successfully attract and retain professional nurses even in times of shortage. These hospitals were described as Magnet Hospitals.
Characteristics of magnet hospitals included: participative management; open communications; quality leadership; a director of nursing at the executive level of the organization; adequate, creative and flexible staffing with favorable nurse-patient and nurse-nonprofessional ratios; competitive salaries and benefits; availability of staff education departments; clinical ladders and career development; high value placed on teaching and education; a positive image of nursing; use of professional practice models; and continuous efforts towards improvement. A follow-up study in 1999 noted that in addition to lower morbidity and mortality rates, shorter lengths of stay, and lower utilization of ICU days, magnet hospitals had lower incidence rates of needlestick injuries among nurses (McClure & Hinshaw, 2002). Hospitals with magnet hospital characteristics provide a practice environment where nursing staff is able to identify ways to eliminate or reduce errors, risks, and negative outcomes.
Nursing research has made a significant contribution to patient safety by identifying the need for adequate staff.
Researchers. Nursing research has made a significant contribution to patient safety by identifying the need for adequate staff. It has been demonstrated that adequate nurse staffing is critical to the delivery of quality patient care because it allows time for appropriate nursing assessment of patients. An ANA study found that adverse patient outcomes including pneumonia, post-operative infections, pressure ulcers, urinary tract infections, and lengths of stay were reduced where nurse-staffing levels were higher (ANA, 2000a). A Vanderbilt University study found that a higher proportion of hours of care per day and a greater absolute number of hours of care per day provided by RNs were associated with better patient outcomes (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Aiken has correlated increased nursing workload to the increased likelihood of patient death (Aiken, 2002). Unruh (2003) has demonstrated that a 10% increase in nurse staffing was associated with fewer adverse patient events.
Nurse researchers have also noted that certification can be used as an indicator for competency. In a recent ANCC study nurses reported the following types of post-certification nursing practice:
- 51% report a greater confidence in practice.
- 35% describe greater confidence in decision-making ability.
- 28% report more confidence in the ability to detect complications.
- 23% report more effective communication and collaboration with other health care practitioners.
- 6% report fewer adverse events and errors in patient care than before they were certified (Whittaker, Smolenski & Carson, 2000).
Continuing research is necessary to determine the impact of nurse-physician relationships, professional autonomy, and RN control over the practice environment upon improved professional practice and the safer delivery of patient care (ANA, 2000b). Also needed is research that identifies the effect of non-punitive reporting systems on health care errors.
Physicians have a longstanding history of monitoring patients’ outcomes to medical treatments and surgical interventions. The American Medical Association (AMA) (www.ama-assn.org) identifies elimination of health systems errors as a high priority for the AMA, and an important ethic of the medical profession. The AMA fosters its commitment to safe outcomes through the efforts of the American Medical Accreditation Program, the National Patient Safety Foundation, and the Performance Measurement Coordinating Council. The AMA urges hospitals, physicians, nurses, pharmacists, drug companies, nursing homes, and others to work together to identify and correct system-wide problems that cause errors or adverse patient outcomes (AMA, 2003).
Greenberg (2002) suggests that encouraging physicians to listen more carefully to nurse colleagues, patients, and family members will also decrease health care errors. He writes:
Nurses are full-fledged partners in the health care equation, offering not only their compassionate perspective but also their eyes, ears and hearts…they have prevented me from doing or saying something foolish, or worse, harming a patient…Nurses are a priceless health care resource that is not being renewed or protected (p.6).
Government and Legislative Bodies
States establish practice acts, rules, and regulations regarding professional nursing practice to authorize and to protect the public from harm by strengthening safe practices. This authorization is contained in each state’s Nurse Practice Act (NPA). Such acts can be general in the description of nursing practice or very specific, listing authorized tasks or acts. While there is general agreement among the states on how to ensure entry-level competence, there has been a long debate on how to ensure continued competency. Some states (N=26) are working to promote patient safety by requiring some form of continuing education (CE) to maintain professional competence. Other measures to promote continuing competence include CE with exit testing, peer review programs, practical demonstrations of competence, proactive fellowship programs, and holding employers responsible for ensuring the competence of the staff (Gragnola & Stone, 1997; Whittaker et al., 2000).
The PEW Health Professions Commission recommends (1995 & 1998) that state licensing/regulatory boards require nurses to demonstrate on-going competence. The 1998 report specifically recommends that the assessment of this professional competence be done by professional associations, private testing companies, and specialty boards (Whittaker et al., 2000).
State legislatures can also provide for safer care through laws designed to improve the nursing workplace environment.
State legislatures can also provide for safer care through laws designed to improve the nursing workplace environment in order to reduce the burden on nurses. This burden reduction would provide an incentive for individuals to enter or return to nursing and encourage nurses to stay active in the profession for longer periods. For example, states could require the establishment of adequate and appropriate staffing methodologies that would include critical elements (e.g., patient acuity, census, skills of the staff, staff mix, geography of the unit, and technology) to be used by a health care facility. Recently, there has been interest in legislatively mandating specific staffing ratios. However, this type of solution will only work if the legislature ensures that the established ratio is indeed a minimum number, not the maximum staffing level. Legislatures could also prohibit the use of mandatory overtime as a staffing method. Other legislation that states could support include: mandated reporting of nursing quality indicators; open public hearings on proposed hospital mergers or closings; required wearing of identification badges by health care practitioners; and protection of the title "nurse." A number of states have already successfully passed whistleblower legislation to protect health care practitioners who identify unsafe or incompetent practice and potentially dangerous institutional practices.
A number of states have already successfully passed whistleblower legislation to protect health care practitioners who identify unsafe or incompetent practice...
U.S. Senator Daniel Inouye (D-HI) has introduced the Registered Nurse Safe Staffing Act of 2003 to mandate the establishment of a safe staffing system as one part of the Medicare conditions of participation. For many years, at the request of ANA, U.S. Representative Maurice Hinchey (D-NY) has introduced legislation called the Patient Safety Act which focuses on major safety, quality, and workforce issues for nurses and their patients. If passed this act will be a requirement for participation in Medicare and Medicaid. Three key provisions of this Act are to:
- Make public specific information on nurse staffing levels, staff mix and patient outcomes, and institutional data regarding complaints filed with a state agency, the Centers for Medicare and Medicaid (CMS), or an accrediting agency related to participating in Medicare.
- Add whistleblower protections to the Medicare law.
- Require institutions seeking mergers or acquisitions to file information regarding the overall impact of such action on the community with the Department of Health and Human Services.
International Council of Nurses. Professional nursing associations are also taking a lead in promoting patient safety. The International Council of Nurses (ICN) (www.icn.ch) states that patient safety is fundamental to quality health and encourages nurses to address patient safety in all aspects of care. ICN supports a systems-wide approach to addressing health care errors, an approach that incorporates measures to assess human and systems factors in adverse events (ICN, 2002).
The American Nurses Association. The American Nurses Association (ANA) (www.nursingworld.org) has provided direction for nurses by developing such items as practice standards and guidelines, ethics statements, a model nurse practice act, and models for workplace collective bargaining agreements. Specifically, ANA, in collaboration with the national specialty nursing associations, has established standards of practice for both generic and specialty nursing areas. The various standards describe a competent level of nursing care that (a) reflects the values and priorities of the profession, (b) provides direction for professional practice, and (c) forms a basis of accountability for all nurses regardless of practice setting. ANA’s Nursing: Scope and Standards of Practice focuses on the processes of providing care (Standards of Care) and performing professional role activities (Standards of Professional Performance)(ANA, 2003b). Nursing’s Social Policy Statement, the social contract that exists between nursing and society, also addresses the provision of quality care (ANA, 2003a).
It is an ethical expectation that the nurse will appropriately report errors according to institutional policy...
Another document that directs the care provided by nurses is the ANA’s Code of Ethics for Nurses. It explicitly expresses the primary goals, values, and obligations of the profession. Provision Three states that "the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient"(ANA, 2001, p. 12). The accompanying interpretative statement notes that nurses are expected to participate in activities, such as review mechanisms designed to safeguard patients and nurses, and also to develop policies and review mechanisms that promote patient safety, reduce errors, and address both system and human factors that contribute to increased risks to patients. It is an ethical expectation that the nurse will appropriately report errors according to institutional policy, assure disclosure of the error to the patient and, under no circumstances, participate in any attempts to hide an error. The Code also expects that the nurse will remedy any harm that might come to a patient and seek to correct the conditions that led to the error in a positive, non-punitive manner (ANA, 2001).
At the 2000 ANA House of Delegates, the nurses voted to support actions to build safe health care systems for patients. Nurses were asked to engage in the following activities:
- Promote awareness about changes in the health care system that undermine quality and safety of patient care.
- Support the development of a National Center for Patient Safety and the establishment of a nationwide mandatory state-based error reporting system.
- Support the development and implementation of performance standards by regulators and accrediting agencies that require health care institutions and systems to implement patient safety programs and processes with defined executive responsibility.
- Support the implementation of proven medication safety systems and practices by health care organization.
- Promote passage of whistle blower legislation that protects the essential role of nurses in efforts to correct system errors.
- Demonstrate the improvement of quality of care and reduction of errors through collection of data using nursing quality indicators.
- Promote nursing research on patient safety and educate nurses in the science of system safety issues.
National Committee for Quality Assurance. The National Committee for Quality Assurance (NCQA) (www.ncqa.org) is a non-profit watchdog organization. This Committee assesses, measures and reports the outcomes of care provided by the nation’s managed care organizations, and manages the evolution of the Health Plan Employer Data and Information Set (HEDIS), the performance measurement tool used by 90% of the nation’s health plans.
National Patient Safety Foundation. The National Patient Safety Foundation (www.npsf.org) is a non-profit research and education foundation. It focuses on error reduction and accidents in health care using an approach that emphasizes systems learning as opposed to methods that focus on only blame and punishment. This Foundation is committed to making patient safety a national priority. It recently released its National Agenda for Action: Patients and Families in Patient Safety, a call to involve patients and families in systems and patient safety programs (National Patient Safety Foundation, 2003).
Institute for Safe Medical Practices. The Institute for Safe Medical Practices (ISMP) (www.ismp.org) is a not-for-profit organization. This Institute analyzes medication errors and has compiled a system for reviewing and cataloguing medication and administration issues.
Agency for Healthcare Research and Quality. The Agency for Healthcare Research and Quality (AHRQ) (www.ahrq.gov) recently requested researchers at Oregon Health and Science University to review 115 existing studies regarding patient safety. The researchers found evidence to support several strategies for improving patient safety, such as (a) increasing nurse staffing levels in acute care hospitals and nursing homes, (b) having experienced physicians and other staff perform complex procedures and certain types of clinical care, (c) reducing interruptions and distractions to staff, and (d) improving systems for exchanging information in the "handoff" between hospitals and other health care settings (AHRQ, 2003). The agency also has developed a series of references that provide advice to patients to assist them in making informed health care decisions and to improve their interactions with health care practitioners and facilities. Some of the titles available are: 20 Tips to Help Prevent Medical Errors, Your Guide to Choosing Quality Health Care, and Ways You Can Help Your Family Prevent Medical Errors. These references are available at: www.ahcpr.gov/news/pubcat.
Since 1996, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (www.jcaho.org) has evolved its Sentinel Event Policy that has reviewed and monitored thousands of sentinel events in an attempt to understand the root causes that precipitate particular events (JCAHO, 2001). These results have been shared to prevent similar sentinel events from occurring and to protect patients. JCAHO has identified nurses as formidable leaders in identifying and preventing specific types of sentinel events (JCAHO, 2001). In (2002) JCAHO released a report noting that the current nursing shortage might threaten patient safety and affect the quality of health care received by patients.
JCAHO’s Sentinel Event Advisory Group, through an intensive process of review of all past sentinel event recommendations, developed the following set of six National Patient Safety Goals, for use by health care organizations:
- Improve the accuracy of patient identification.
- Improve the effectiveness of communication among caregivers.
- Improve the safety of using high-alert medications.
- Eliminate wrong-site, wrong-patient, wrong-procedure surgery.
- Improve the safety of using infusion pumps.
- Improve the effectiveness of clinical alarm systems (JCAHO, 2003a)
JCAHO has made available online with free, unrestricted access its September 2003 Special Report of the Joint Commission Perspectives on Patient Safety. It is entirely devoted to JCAHO’s patient safety goals and provides advice and tips for meeting these goals. As this article went to press, JCAHO announced a seventh patient safety goal for 2004 that addresses nosocomial infections (JCAHO, 2003b).
JCAHO, given its widespread and influential accrediting position, is in an unique position to require health care organizations to provide a clear articulation of organizational values and to address perceived lapses in ethical behavior that may adversely impact safe patient care or professional conduct (Fletcher, Sorrell & Silva, 1998). The Leapfrog Group (www.leapfroggroup.org), a group of CEOs from 100 of the nation’s largest corporations, cites patient safety as one of its major objectives in reviewing health care delivery systems. JCAHO is a member of the Leapfrog Group and will assist the group in the identification of a specific set of intensive care, unit-related measures.
Patients are entitled to safe, quality care. Many stakeholders are working to enhance safe care for all. This article has reviewed what these stakeholders have already done to promote safe care and suggests additional activities that can further enhance the safety of our care for future patients. Nurses are playing, and will continue to play, an ongoing role in the movement to promote safe care. Nurses remain a key strand in the health care safety net.
Karen A. Ballard, MA, RN
Karen A. Ballard, MA, RN is the Director of the Practice and Governmental Affairs Program of the New York State Nurses Association where she responds to nursing practice problems from across the state, interacts with state agencies interpreting nursing practice issues, and has served as the association’s regulatory lobbyist. Currently, she is assigned to special projects such as emergency preparedness, bioterrorism and smallpox, third party reimbursement, nursing intensity weights, and the nursing shortage. Ms. Ballard has her Bachelor’s degree in nursing from Niagara University and her Master’s degree in child and adolescent psychiatric mental health nursing from New York University. She has served on several state commissions and task forces including a Public Health Council Subcommittee on Confidentiality. She is a published author and producer of audiovisual materials including a videotape on Preparing Children for the Hospital Experience. Ms. Ballard’s most recent publications include a chapter on nursing practice in Your Career in Nursing, a textbook titled Psychiatric Nursing–An Integration of Theory and Practice, and an article on "Measuring Variations in Nursing Care Across DRGs" in Nursing Management.
Agency for Healthcare Research and Quality. (2003). The effect of health care working conditions on patient safety. Bethesda, MD: AHRQ. Available from: www.ahrq.gov/clinic/epcsums/worksum.htm.
Aiken, L. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. JAMA: Journal of the American Medical Association, 288: 1987-1993.
American Association of Critical Care Nurses. (1990). Delegation of nursing activities in critical care – A framework for decision-making. Alsio Viejo, CA: ACCN.
American Medical Association. (2003). Patient safety. Available from: www.ama-assn.org/ama/pub/category/6301.html.
American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. Washington, DC: ANA.
American Nurses Association. (2000a). Nurse staffing and patient outcomes in the inpatient hospital setting. Washington, DC: ANA.
American Nurses Association. (2003a). Nursing’s social policy statement. Washington, DC: ANA.
American Nurses Association. (2003b). Nursing: Scope and standards of practice. 3rd edition. Washington, DC: ANA. [Available late October 2003].
American Nurses Association. (2002, September 24). Statement of the American Nurses Association for the Institute of Medicine’s Committee on Work Environment for Nurses and Patient Safety. Washington, DC:ANA, 1-8. Available from: www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2006_1/ANAonWorkEnvironment.aspx.
American Nurses Association. (2000b, September 11). Testimony for the National Summit on Medical Errors and Patient Safety Research. Washington, DC: ANA. Available from: www.nursingworld.org/FunctionalMenuCategories/MediaResources/PressReleases/2000/HospitalStaffingIssues.aspx.
American Organization of Nurse Executives. (2000). AONE on Patient Safety. Retrieved on September 15, 2003 from www.hospitalconnect.com/aone/keyissues/patient_safety.html.
Ballard, K. A. (2002). The world of nursing practice. In A. Vallano, Your Career in Nursing. New York: Simon and Schuster.
Buerhaus, P. (Winter 2000). News and Views. Providence: Rhode Island State Nurses Association.
Cronenwett, L.R. (2002). Research, practice and policy: Issues in evidence based care. Online Journal of Issues in Nursing. Available from: www.nursingworld.org//MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/KeynotesofNote/EvidenceBasedCare.aspx.
Fletcher, J.J., Sorrell, J and Silva, M.C. (1998). Whistleblowing as a failure of organizational ethics. Online Journal of Issues in Nursing. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/KeynotesofNote/EvidenceBasedCare.aspx.
Gragnola, C.M. and Stone E. (1997). Considering the future of health care workforce regulation. USFC Center for the Health Professions. San Francisco, CA.
Greenberg, M. (2002). Hailing one of health care’s priceless resources – nurses. Tennessee Nurse/Tennessee Nurses Association (65)5, 6.
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Retrieved September 15, 2003 from www.nap.edu/books/0309068371/html.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century – Summary. Washington, DC: National Academy Press, 2-4. Available from www.nap.edu/books/0309072808/html.
International Council of Nurses. (2002). Position statement on patient safety. Geneva, Switzerland: ICN.
Joint Commission on the Accreditation of Healthcare Organizations. (2001). Front line of defense: The role of nurses in preventing sentinel events. Chicago, IL: JCAHO.
Joint Commission on the Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Chicago, IL: JCAHO.
Joint Commission on the Accreditation of Healthcare Organizations. (2003a). 2003 JCAHO national patient safety goals: Practical strategies and helpful solutions for meeting these goals. Joint Commission Perspectives on Patient Safety, 3 (1).
Joint Commission on the Accreditation of Healthcare Organizations. (2003b). JCAHO national patient safety goals approved. Joint Commission Perspectives, 23 (9), 1, 3.
McClure, M., Poulin, M., Sovie, M., & Wandell, M. (1983). Magnet hospitals. Kansas City, MO: American Nurses Association.
McClure, M. and Hinshaw, A. S. (2002). Magnet hospitals revisited. Washington, DC: American Nurses Publishing.
Murray, M. (2002). The nursing shortage: Past, present and future. Journal of Nursing Administration, 32, p. 79-84.
National Patient Safety Foundation. (2003). National agenda for action: Patients and families in patient safety – Nothing about me, without me. Chicago, IL. Author, 1-12.
Needleman, J., & Buerhaus, P. (2003). Nurse staffing and patient safety: Current knowledge and implications for action. International Journal for Quality in Health Care, 15(4), 275-277.
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., and Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346: 1715-1722.
New York State Nurses Association. (1997). Assessing your nursing practice environment: A guide for nurses seeking employment in health care settings. Latham: NYSNA, 1-4.
Nightingale, F. (1859). Notes on nursing: What it is and what it is not. London: Harrison and Sons. (A facsimile edition, 1946). Phildalphia: J.B.Lippincott Company.
Reason, J. (1990). Human error. New York: Cambridge University Press, 1-10.
Unruh, L. (2003). Licensed nurse staffing and adverse events in hospitals. Medical Care, 41, 142-152.
Whittaker, S., Smolenski, M., and Carson, W. (2000). "Assuring continued competence – Policy questions and approaches: How should the profession respond?" Online Journal of Issues in Nursing. Available from: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume52000/No3Sept00/ArticlePreviousTopic/ContinuedCompetence.aspx
© 2003 Online Journal of Issues in Nursing
Article published September 30, 2003
- Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings
Mary Ann Lavin, ScD, APRN, ANP-BC, FNI, FAAN; Ellen Harper, DNP, RN-BC, MBA, FAAN; Nancy Barr, MSN, RN (April 14, 2015)
- Nurses with Undiagnosed Hearing Loss: Implications for Practice
Cara S. Spencer, MSN, FNP-BC; Karen Pennington, PhD, RN (January 5, 2015)
- Avoiding Negative Dysphagia Outcomes
Dennis C. Tanner, PhD; William R. Culbertson, PhD (April 23, 2014)
- Electronic Health Record: Driving Evidence-Based Catheter-Associated Urinary Tract Infections (CAUTI) Care Practices
Lois M. Welden, MSN, RN (August 6, 2013)
- Elder Mistreatment and the Elder Justice Act
Nancy L. Falk, PhD, MBA, RN; Judith Baigis, PhD, RN, FAAN; Catharine Kopac, PhD, DMin, RN, CGNP (August 14, 2012)
- Promoting Safe Use of Medical Devices
Sonia C. Swayze, RN, MA; Suzanne E. Rich, RN, MA, CT (October 17, 2011)
- The Professional Nursing Association’s Role in Patient Safety
Patricia A. Rowell, PhD, RN, CNP (September 30, 2003)
- Improving Quality and Patient Safety by Retaining Nursing Expertise
Karen S. Hill, DNP, RN, NEA-BC, FACHE (August 2, 2010)
- Vigilance: The Essence of Nursing
Geralyn Meyer, PhD, RN; Mary Ann Lavin, ScD, RN, FAAN (June 23, 2005)
- Measuring Fall Program Outcomes
Pat Quigley, PhD, MPH, ARNP, CRRN, FAAN; Julia Neily, RN, MS, MPH; Mary Watson, MSN, ARNP, BC; Marilyn Wright, BSN, RN.C; Karen Strobel, RN, MSN (March 2, 2007)
- Survey of Advanced Practice Registered Nurses Disciplinary Action
Randall Hudspeth, MS, APRN-CNS/NP (April 2, 2007)
- Health Systems’ Accountability for Patient Safety
David Keepnews, PhD, JD, RN, FAAN; Pamela H. Mitchell, PhD, RN, FAAN (September 30, 2003)
- Contributions of the Professional, Public, and Private Sectors in Promoting Patient Safety
Evelyn D. Quigley, RN, MN (September 30, 2003)