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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) published "To Err Is Human: Building A Safer Health System." The report found that medical error is the 8th leading cause of death in America. The report also found that reluctance to report errors impedes patient safety improvements by obscuring the dimensions of the problem. The 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." A "culture of safety" is one that incorporates safety principles that include:

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.

A subsequent IOM publication (2008), “Creating a Business Case for Quality Improvement and Quality Improvement Research, ”identified a number of impediments that hamper patient safety improvement." Some of the barriers include:

competing stakeholder priorities
refusal to acknowledge a problem
fear of punishment and blame
limited resources
incomplete data collection
lack of data sharing
systems inertia

Nurses are inherently part of the medical error/patient safety problem and undeniably at the center of any meaningful effort to improve patient safety. 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 Nursing Process identifies the steps nurses must take to protect the patient from harm:

assess the risk of adverse events
plan avoidance of harm
implement an improvement plan
evaluate success.

Assessment results in an appraisal of current status and future needs. It requires the deliberate, inclusive and accurate collection of all details surrounding an identified risk or event. An "incident report" is a powerful tool with which to begin data collection. It is the first step toward overcoming each of the barriers highlighted by the “Creating a Business Case for Quality Improvement and Quality Improvement Research” report. It focuses stakeholders on patient safety. It diminishes blame and shame by concentrating on the incident rather than the actors. The incident report initiates system-specific data analysis. All of these factors prepare the way for a plan.

Planning outlines the steps necessary to move from the current status to the desired outcome. Ideally, the reporting individual should be engaged throughout the organization's corrective actions. Identifying and reporting an event is valuable to the system and the system acknowledges this by involving the reporter in its efforts to improve.

Implementation requires involvement of all stakeholders. Frontline personnel must be empowered to make the necessary changes. Nursing and administrative resources must be adequate to the needs identified in the plan. Inappropriate allocation of resources may inhibit nursing science and access to relevant statistics, signaling a serious systemic failure.

Evaluation identifies successes and isolates shortcomings. Nursing participation in the evaluation process acknowledges its status as a primary stakeholder in patient safety improvement. It also reinforces success and the benefits derived from collegial cooperation/communication.

Instant feedback:

The "Incident Report" is an important patient safety tool.

Definitions:

Adverse event - An adverse event is any unexpected or dangerous outcome that results from a medical intervention.
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.
Patient safety - Freedom from accidental injury; 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 errors do occur.
Stakeholder - a person who has an interest or concern in an outcome. Healthcare stakeholders include: consumers, doctors, nurses, administrators, insurance companies, etc. Each has an interest in patient outcomes but each has different resources, expectations and responsibilities.