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Introduction

"It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm."

Florence Nightingale (1859)

In 1999, the Institute of Medicine (IOM) exposed the patient safety failure of the American healthcare industry when it published "To Err Is Human: Building A Safer Health System." This report identified medical error as the 8th leading cause of death in America. The report found that reluctance to report errors impedes patient safety improvements by obscuring the dimensions of the problem. The IOM report concluded that our decentralized and fragmented healthcare system fails to provide adequate patient safety. Finally, the report calls on healthcare organizations to implement a "culture of safety" that reduces the chance of human error by:

designing jobs and working conditions for safety
standardizing and simplifying equipment, supplies, and processes
reducing reliance on memory
improving access to relevant information
investing in continuous patient monitoring technology.

Definitions:

Adverse event - An adverse event is any unexpected or dangerous outcome that results from a medical intervention. The National Quality Forum (NQF) had expanded the definition to include events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.
Medical error - The Institute of Medicine defines medical error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
Never event - refers to particularly shocking medical error (such as wrong-site surgery) that should never occur.
Sentinel events – The Joint Commission defines a sentinel event as a “patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm. An event is also considered sentinel if it is one of the following:

Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)
Unanticipated death of a full-term infant
Discharge of an infant to the wrong family
Abduction of any patient receiving care, treatment, and services
Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition (The Joint Commission, 2016).”

Hospital Acquired Conditions - Centers for Medicare & Medicaid Services (CMS) have a list of 14 hospital acquired conditions (HACs). These are adverse events that occur during a hospital stay that are preventable using evidenced based practice approaches (see Appendix).

Impact of the IOM report

The IOM report brought significant public attention to the preventable harm and mortality caused by our healthcare industrial practices. In 2006, the U.S. Congress charged the Department of Health and Human Services - Office of Inspector General (OIG) with reporting the incidence of never events among Medicare beneficiaries, the payment for services in connection with such events, and the Centers for Medicare & Medicaid Services (CMS) processes to identify events and deny payment.• The 2010 OIG report estimated 1.5 percent of Medicare beneficiaries hospitalized in 2008 experienced an adverse medical event that contributed to their deaths. The estimate indicates that 15,000 hospitalized Medicare patients experienced preventable death every month during 2008.

State reporting requirements

To date, 27 states require hospitals to report adverse events that occur. Most states have systems in place to assist hospitals in reducing the number of adverse effects.

CA, CT, IL, IN, MN, NJ, OR, VT,* WA, WY CO, FL, GA,
KS, MA, MD, ME, NV, NY, PA, OH, RI, SC, SD, TN, TX, UT

Lack of precise estimates of adverse and never events.

A major issue in estimating adverse events is the lack of accurate data. According to an AHRQ report there is no consistent and valid reporting system of patient safety events. The actual number of patients who are harmed by poor safety standards is unknown. Most hospitals use their incident reports, medical records descriptions or discharge ICD 10 reports to identify medical errors. All of these reports are collected after the occurrence of the incident, retrospectively. Real-time measures by observers, a prospective approach, would be more accurate. There is also confusion about distinguishing between patient safety events and an expected side effect of treatment. There are reports that hospital administrators use expected side effects too frequently when the event should be reported as a safety issue (Clark, 2012).

Nursing’s role in safety

Nurses are inherently part of the medical error/patient safety problem and undeniably at the center of any meaningful effort to improve patient safety. Nurses are key to keeping patients free from accidental injury as well as establishing operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them before errors do occur.
Patient safety science was pioneered by Florence Nightingale nearly two centuries ago. Ms. Nightingale remains famous for her ability to identify a problem and then mobilize resources to minimize associated risk. Florence Nightingale still speaks clearly to today's nurse: "do the sick no harm."

The American Nurses Association (ANA) recently expanded the nursing process to include steps useful to reducing adverse events. The Nursing Process is the critical thinking model that forms the foundation of the nurse’s decision-making.

Applying New ANA Standards of Professional Nursing Practice

Standard

Patient Safety Intervention

1. Assessment

RN systematically collects physical and historical data relevant to the patient's health status (intrinsic factors) that may increase the risk of exposure to an adverse event.

2. Diagnosis

RN analyzes patient intrinsic factors and extrinsic factors e.g., Clinical Unit environment, anticipated treatments, ect. to identify the patient's potential exposure to specific adverse events, e.g. Fall risk, Medical allergy, Latex allergy, Restricted Extremity, DNR, Dietary Restrictions, Elopment Risk, etc.

3. Outcomes Identification

RN designates expected patient outcome goals for the identified potential adverse event exposures.

4. Planning

RN develops a patient centered safety care plan using safety protocols, prior root cause analysis and best practice strategies to meet patient safety outcome goals .

5. Implementation

RN initiates the plan to meet outcome goals through mitigation or elimination of patient harm from exposure to identified potential adverse events.

5A. Coordination of Care

Nurse coordinates care delivery by communicating the patient centered safety plan to ensure appropriate staffing, safety device allocation and specialty consults, i.e. Dietary, Pharmacy, PT, etc. RN adjusts care plan as needed.

5B. Health Teaching and Health Promotion

Nurse employs patient-centered teaching strategies including teach-back to promote patient safety and optimize patient health outcomes.

6. Evaluation
RN regularly evaluates the efficacy of the patient safety care plan and whenever health condition or treatment changes.

Applying New ANA Standards of Professional Nursing Practice
Standard	Patient Safety Intervention
1. Assessment	RN systematically collects physical and historical data relevant to the patient's health status (intrinsic factors) that may increase the risk of exposure to an adverse event.
2. Diagnosis	RN analyzes patient intrinsic factors and extrinsic factors e.g., Clinical Unit environment, anticipated treatments, ect. to identify the patient's potential exposure to specific adverse events, e.g. Fall risk, Medical allergy, Latex allergy, Restricted Extremity, DNR, Dietary Restrictions, Elopment Risk, etc.
3. Outcomes Identification	RN designates expected patient outcome goals for the identified potential adverse event exposures.
4. Planning	RN develops a patient centered safety care plan using safety protocols, prior root cause analysis and best practice strategies to meet patient safety outcome goals .
5. Implementation	RN initiates the plan to meet outcome goals through mitigation or elimination of patient harm from exposure to identified potential adverse events.
5A. Coordination of Care	Nurse coordinates care delivery by communicating the patient centered safety plan to ensure appropriate staffing, safety device allocation and specialty consults, i.e. Dietary, Pharmacy, PT, etc. RN adjusts care plan as needed.
5B. Health Teaching and Health Promotion	Nurse employs patient-centered teaching strategies including teach-back to promote patient safety and optimize patient health outcomes.
6. Evaluation	RN regularly evaluates the efficacy of the patient safety care plan and whenever health condition or treatment changes.