The Nurse’s Role in Promoting a Culture of Patient Safety
Mary Ann Friesen, MSN, RN, CPHQ
Doctoral Student
College of Nursing and Health Science
George Mason University, Fairfax, VA
Mary Beth Farquhar, MSN, RN*
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality, Rockville, MD
Ronda G. Hughes, PhD, MHS, RN*
Center for Primary Care, Prevention and Clinical Partnerships
Agency for Healthcare Research and Quality, Rockville, MD
*The views in this article are those of the authors and do not necessarily reflect those of the
Agency for Healthcare Research Quality or the U.S. Department of Health and Human Services
The authors wish to acknowledge Robert Reilly PharmD and Kate Sandy MSN, RN for their review of portions of
this Continuing Education Module
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Abstract
There are varying consequences of medical errors. Ironically, these errors involve those
intending to help, not harm patients. Though errors are often blamed on individuals, the true
roots of these errors are found in the combination of the workplace environment in which
healthcare is delivered and in the interaction among healthcare providers. To understand the
causes of error, it is important to consider the dynamics of healthcare as a system, influenced by
individuals and culture. For medical errors to decrease and for patient safety to improve, our
healthcare system needs to change.
Nurses are in a unique position to improve patient safety because of their inherent
proximity to patients. This position gives nurses the needed insight to identify problems in
healthcare systems and to be part of patient safety solutions. However, to do this, nurses must be
supported and encouraged without fear of retribution, as well as have an understanding of how
organizational culture change can be accomplished. As such, the purpose of this paper is to
present an overview of patient safety problems associated with organizational culture and how
nurses can be part of organizational change promoting patient safety. After completion of this
module, nurses will be able to:
1. Describe the risks medical errors pose to patient safety
2. Discuss the culture of safety
3. Compare and contrast the culture of safety with the culture of blame
4. Describe strategies to promote a culture of safety in the healthcare environment
2
The Problem of Medical Errors
More than 140 years ago, Florence Nightingale warned, “the very first requirement in a
Hospital is that it should do the sick no harm” (Nightingale, 1863, preface). This concern was
echoed in Crossing the Quality Chasm: A New Health System for the 21st Century, where the
Institute of Medicine (IOM) called for safety in the delivery of healthcare indicating that
“patients should be safe from injury caused by the care system” (Institute of Medicine, 2001, p.
8). Today, the increasing complexity of healthcare has contributed to the growing problem of
medical errors (Wachter, 2004). According to the Committee on Quality of Healthcare in
America, the majority of quality problems and medical errors occur “because of fundamental
shortcomings in the ways care is organized” (Institute of Medicine, 2001, p. 25), not individual
error or negligence (Kohn, Corrigan, & Donaldson, 2000).
The pervasiveness of medical errors garnered widespread attention after the IOM
published its seminal report, To Err is Human: Building a Safer Health System (Kohn et al.,
2000). This report was a catalyst in focusing national attention on the need for patient safety
improvement and higher quality healthcare. The report found that medical errors not only
impede the quality of care but are responsible for 44,000 to 98,000 patient deaths per year (Kohn
et al., 2000). The costs of errors are estimated at $17 billion to $29 billion (Kohn et al., 2000)
and have devastating effects and emotional costs for patients and their families (Gibson and
Singh, 2003).
In an effort to respond to the concerns cited in the IOM reports, the U.S. Senate
Appropriations Committee directed the Agency for Healthcare Research and Quality (AHRQ) to
“lead the national effort to combat medical errors and improve patient safety” (Agency for
Healthcare Research and Quality, 2004, p. 1). Since that time, AHRQ has taken the lead in
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advancing the patient safety agenda by funding health services research in this area. Patient
safety can be defined as “freedom from accidental injury; ensuring patient safety involves the
establishment of operational systems and process that minimize the likelihood of errors and
maximizes the likelihood of intercepting them when they occur”(Kohn et al., 2000, p. 211).
What are Medical Errors and Adverse Events?
Medical errors are defined in a number of ways. The AHRQ defines them as “mistakes
made in the process of care that result in or have the potential to do harm to patients” (Agency
for Healthcare Research and Quality, 2004,p. 57). The IOM defines errors as “the failure of a
planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to
achieve an aim (i.e., error in planning)” (Kohn et al., 2000, p. 28). An adverse event is defined
as “an injury caused by medical management rather than the underlying condition of the patient.
An adverse event attributable to error is considered a “preventable adverse event” (Kohn et al.,
2000, p. 28).
Why Do Errors Occur?
There are two approaches to understanding human error. One is the “person approach”
(Reason, 2000), which focuses blame on the individual for failures such as forgetfulness or
carelessness. The other approach focuses on systems and how they contribute to errors (Reason,
2000). Reason identified types of errors as: active and latent (Reason, 1990). The active error
type of incident is the result of noncompliance with a procedure, or making a mistake such as not
assuring the correct identification of the patient before administering the medication. A latent
condition involves problems within the system. Reason noted that latent errors “may lie dormant
within the system for a long time” (Reason, 1990, p. 173). It is important to note that “latent
4
errors pose the greatest threat to safety in a complex system” (Reason, 1990, p. 173) because
they may lead to additional errors.
Research in patient safety funded by AHRQ has identified a number of factors associated
with medical errors including:
•
Communication problems―including both verbal and written communication among
all levels of healthcare providers in various settings;
•
Inadequate information flow―need for information to appropriately care for and
manage the patient through the continuum of care;
•
Human problems―lack of appropriate clinical knowledge, failure to follow policy
and procedures;
•
Patient-related issues―lack of appropriate patient education;
•
Organizational knowledge transfer―lack of appropriate orientation, staff
development, education, and training;
•
Staffing patterns―inadequate staff and supervision can contribute to situations that
are at high risk for medical errors;
•
Technical failures―medical equipment failure or occurrence of errors related to poor
design of medical equipment; and
•
Inadequate policies and procedures―lack of procedure to guide delivery of care
(Agency for Healthcare Research and Quality, 2004).
Nurses are in a unique position to improve patient safety because of their proximity to the
patient and their critical role in healthcare delivery. This position gives nurses the needed insight
to identify and address errors.
Recognizing and Reporting Errors
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Medical errors cannot be addressed if they are not recognized and reported. In one study,
74 percent of nurses surveyed perceived errors “were reported less than 50 percent of the time”
(Osborne, Blais, & Hayes, 1999, p. 35). In another study, nurses perceived that only 60 percent
of medication administration errors were reported (Wakefield, Wakefield, Borders, UdenHolman, Blegen, & Vaughn, 1999). In both studies, nurses perceived an underreporting of
errors.
Barriers leading to underreporting of medical errors by nurses include: burdensome
documentation requirements, inability to report errors anonymously, hesitancy to report on
another, unclear reporting requirements for errors without an adverse outcome and “fear of
lawsuits” (Uribe, Schweikhart, Pathak, & Marsh, 2002, p. 273). Additionally, nurses are often
reluctant to report errors if they perceive that reporting errors will not lead to needed changes
(VanGeest & Cummins, 2003). A number of articles have addressed various reasons medication
errors are not reported (Osborne et al., 1999; Wakefield, Wakefield, Uden-Holman, Borders,
Blegen, & Vaughn, 1999).
Failure to acknowledge and report errors impedes efforts to improve patient safety. Only
when errors are openly recognized can the reasons causing errors be addressed and subsequent
errors prevented (Hughes, 2004). In fact, the IOM reported that “the biggest challenge to
moving toward a safer health system is changing the culture from one of blaming individuals for
errors to one in which errors are treated not as personal failures, but as opportunities to improve
the system and prevent harm” (Institute of Medicine, 2001, p. 79).
Acknowledging errors requires an environment based on trust and mutual respect where
nurses are motivated, supported, and encouraged to be part of patient safety improvements
without fear of retribution (Page, 2004). Cultures that encourage and sustain this type of work
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environment promote innovative ideas that can lead to improved patient care. The AHRQ
indicated that “a culture of reporting where information is confidential and non-discoverable is
the most significant incentive to reduce medical errors ” (Agency for Healthcare Research and
Quality, 2004, p.25).
Organizational Culture Influences Medical Errors
Organizations have cultures, and daily work life is infused with it. Culture influences
communication, social relations, and individual actions and motivations, as well as the rules,
perspectives, and ideals by which people live (Hecht, Jackson, & Pitts, 2005). Factors such as
how nursing units are arranged, the working atmosphere, and the relations among people vary
among organizations, even within the same industry. Organizational culture can be defined as:
“the underlying values, beliefs, and principles that serve as a foundation for an
organization’s management system as well as the set of management practices and
behaviors that both exemplify and reinforce those basic principles. These principles and
practices endure because they have meaning for the members of an organization.”
(Denison, 1990, p. 2).
Healthcare organizational culture has a profound effect on patient safety and quality of
care. Simply put, if the culture does not promote a safe environment where errors are identified
and reported, patient care delivery will be adversely affected.
Errors are more likely to be reported when clinicians “feel safe to do so and it becomes a
culturally accepted activity” (Cohen, 2000, p. 729). Failure or resistance to reporting errors
because of fear is characteristic of a culture of blame (Larson, 2000). A culture of blame is
exemplified by the lack of communication and silence following medical errors and adverse
events. Conversely, a culture of safety is defined by the Advisory Committee on the Safety of
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Nuclear Installations (ACSNI) as “the product of individual and group values, attitudes,
perceptions, competencies and patterns of behavior that determine the commitment to, and the
style and proficiency of an organization’s health and safety management. Organizations with a
positive safety culture include communications founded on mutual trust, shared perceptions of
the importance of safety, and by confidence in the efficacy of preventive measures.” (From the
Health and Safety Commission of Britain. Organising for Safety: Third Report of the ACSNI
Study Group on Human Factors (sic) (as cited in Sorra & Nieva, 2004, p. 1)
In other words, a culture of safety emphasizes “why” the error occurred rather than
“who” made the error (Hughes, 2004). Characteristics of the culture of safety and the culture of
blame are compared in Table 1. To prevent medical errors, healthcare can apply lessons learned
from high-risk industries that have been successful in changing their culture, resulting in
decreased errors and safety improvement.
Lessons from Other Industries
The aviation and nuclear power industries, both considered high-risk industries, have
implemented incident-reporting systems in an effort to improve safety (Barach & Small, 2000). The
aviation industry gathers data about the occurrence of errors, near misses, and incidents that could
potentially lead to errors via confidential, voluntary, self-reporting systems (Aviation Safety
Reporting System, 2004a, 2004b). The culture within aviation emphasizes effective communication
and teamwork (Pape, 2003), while avoiding a culture based on blame and punishment (Helmreich,
Musson, & Sexton, 2001; Hughes, 2004). Dotan reported in one aviation case example that changing
a reporting system from a punitive system to one focused on improvement resulted in an increase in
reports, but a decrease in the accident rate by 50 percent (Dotan, November 2003).
8
The experiences and lessons learned from these industries can be applied to healthcare. For
example, interventions used in aviation were applied to the process of medication administration
and resulted in a significant decrease of interruptions during medication administration (Pape,
2003). Research conducted comparing pilots and healthcare professionals’ perceptions of fatigue
are also very informative. A study of pilots, nurses, and doctors explored perceptions of fatigue and
found 26 percent of pilots, 55-64 percent of nurses and 47-70 percent of doctors reported they could
perform effectively when fatigued (Sexton, Thomas, & Helmreich, 2000). While nurses,
physicians, and pilots are “expected to function without error” (Sexton et al., 2000, p. 747), the
differences cited in the research may be partially accounted for by the differences in work
cultures of healthcare providers and pilots. The culture in the aviation industry promotes safety
by restricting pilot flight and promoting rest times to avert the adverse effects of fatigue. (Federal
Aviation Administration, 2001, 2005a, 2005b) The IOM report Keeping Patients Safe:
Transforming the Work Environment of Nurses recommends limiting the hours of nurses
providing direct patient care to twelve hours in a 24 hour period and 60 hours in a seven day
period. (Page 2004)
Studies aimed specifically at healthcare providers present sobering data about fatigue and
patient safety. In a study of 393 nurses, it was reported that errors were three times more likely to
occur when a nurse worked a prolonged shift, e.g., longer than 12.5 hours (Rogers, Hwang, Scott,
Aiken, & Dinges, 2004). In another study of more than 600 nurses, concerns related to the effects of
rotating shifts and adequate sleep patterns were identified as factors that affected patient safety. The
investigators found that the odds of a nurse making an error were “twice as high” among nurses who
rotated shifts compared with nurses working straight days or evenings (Gold, Rogacz, Bock,
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Tosteson, Baum, Speizer, & Czeisler, 1992). Together, nurses should explore innovative solutions,
based on evidence, to address work-related fatigue so as to minimize the occurrence of errors that
threaten patient safety (Hughes & Rogers, 2004).
Patient Safety and the Role of Culture: A Case Study
It is important to understand what a culture of safety entails in the workplace. The
following case study illustrates the differences in a culture of safety versus a culture of blame.
This case study presents two organizations with different cultures and their responses to a patient
safety concern identified by the nursing staff. Other organizations may discover different or
additional factors that could lead to “near misses” or “errors” and may develop customized
strategies to improve care. This case study is provided for illustrative purposes only.
Laura Brown, RN is a new nurse working with a preceptor, Sally Grant, RN at a
community hospital. Laura receives medication in a syringe from the pharmacy for one of her
patients. Prior to administering the drug, she notes that the route of administration for the
medication in the syringe is oral. While doing so, she notices the syringe looks like an
intravenous (IV) syringe. Laura identifies a potential error that could happen if the oral syringe
was mistaken for IV use. Ms. Brown seeks out her preceptor to tell her about her observation.
Response in a Culture of Blame: When Laura speaks with her preceptor about the
incident, Sally incredulously responds by saying, “I cannot believe you could think such an error
could occur. What are you thinking?” Sally then proceeds to lecture Laura that she works in a
busy unit, and that she is responsible for any medication errors that she causes and that she must
pay attention and be vigilant; after all, errors occur when nurses don’t do their jobs well. Sally
then continues warning Laura that “you could cause serious harm to patients if you are not
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careful.” Ms. Brown feels like she has failed and is concerned that if this is the reaction when a
potential problem is identified, then what would happen if an error actually occurred?
Response in a Culture of Safety: After Laura relates the incident to her preceptor, Sally
commends Laura for raising the concern that oral medication could mistakenly be administered
intravenously because the syringes look almost identical. Sally contacts the pharmacy to discuss
the concern. Together, the pharmacy and nursing teams meet to conduct an analysis of the “near
miss” incident. The multidisciplinary team uses a root cause analysis (RCA) approach (VA
National Center for Patient Safety, 2005b, 2005c) to identify contributing factors to the “near
miss” incident. The team reviews current practice to determine what happened, why it happened,
and what to do to prevent it from recurring (VA National Center for Patient Safety, 2005c). In
assessing what happened, the team realizes that the type of syringe dispensed with the oral
medication could potentially contribute to the medication being administered incorrectly because
both the oral and IV syringes do look very similar. After completing the analysis, the team
developed a customized action plan for its organization to help prevent such incidents from
occurring. Based on its unique organization, the team developed the following action plan:
1. Obtain specific syringes for oral use that look different than
intravenous/parenteral syringes (Institute for Healthcare Improvement, Paparella,
2004) and that are “designed to be incompatible with IV ports and needles”
(Woods, 2003, p. 6).
2. Ensure that all oral syringes dispensed from the pharmacy are clearly labeled “for
oral use only” to alert healthcare providers.
3. “Store oral syringes separately” (Institute for Healthcare Improvement)
from intravenous/parenteral syringes.
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4. Revise policy and procedures to reflect the need to use oral syringes “only” for
oral medication and other safety interventions related to safe administration of
medication.
5. Provide education programs for nursing, pharmacy, medical staff, and ancillary
staff to communicate changes and reasons for change in the policy and
procedures.
6. Monitor compliance with newly revised policy and procedures in units.
Determine if the changes are adequately addressing the original problem.
Encourage vigilance in use of new syringes to identify any unanticipated
problems. Be prepared to address additional concerns.
7. Personally thank pharmacy and nursing staff members that identified the safety
concerns, and the team that conducted the root cause analysis and developed the
recommendations to improve safety within the organization.
8. Reinforce using the seven rights when administering medication to avoid errors
(right patient, right medication, right dose, right time, right route, right reason,
and right documentation) (Pape, 2003).
9. The action plan will include tasks to be completed, persons responsible, and due
dates.
In this example, the key aspect of a culture of safety is an effort to analyze incidents in a
nonbiased, interdisciplinary manner and ultimately improve patient care through an analysis
process. Unlike a culture of safety, the response in a culture of blame did not explore other
factors (e.g., the design of the syringe) or influences that could have contributed to the situation.
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In a culture of blame, there was not an attempt to analyze the situation to prevent recurrences or
report the concern. Further, the atmosphere is punitive with a lack of supportive communication.
Because Sally reacted to Laura’s actions in a punitive way, Laura will most likely be reluctant to
share such concerns in the future. As a result, there is a missed opportunity to improve patient
care in this organization with this type of environment.
As illustrated in the case example, a culture of safety is beneficial because the reasons
for the “near miss” or “error” are analyzed and discussed in a supportive way. Potential
solutions and approaches are identified by interdisciplinary teams in a collaborative atmosphere
(VA National Center for Patient Safety, 2005c). Open, honest communication is encouraged,
(Page, 2004) and input is sought from the staff. Once a viable strategy is identified, the solution
will be implemented and disseminated throughout the organization. Once disseminated, followup is essential. An evaluation of the solution should be completed and revisions should be
instituted to alleviate gaps or problems identified with the proposed solution. This is a
continuous cycle of assessment, planning, implementation, and evaluation familiar to nurses. In
a culture of safety, those that report “near misses” are recognized positively for identifying a
potential patient safety concern and for calling attention to a system problem, thereby improving
the quality of care delivered at this organization. A culture of safety supports the reporting of
“near misses” and errors to improve the delivery of care (VA National Center for Patient Safety,
2005a).
Moving Toward a Culture of Safety
Nurses are an integral part of the healthcare delivery system, being in a unique position to
make patient care as safe as possible. The development of a culture of safety has three stages:
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Stage 1: Emphasis is on complying with regulatory standards and meeting technical
requirements.
Stage 2: Good safety performance is seen as an organizational goal and valued as being
important.
Stage 3: The culture of safety permeates the organization and there is an emphasis on
continuous improvement. (Page, 2004).
To move from a culture of blame toward a culture of safety, change is necessary.
Elements in a change process include leadership, effective communication, redesign to support
the change, training and education programs, and an ongoing measurement of progress that
incorporates reward and recognition strategies (Vestal & Spreier, 1997). The culture of safety as
described by the IOM includes leaders and managers committed to promoting a culture of safety
at all levels of the organization, and empowers employees to be attentive to and observant of
potential problems that need to be addressed (Page, 2004). Open communication is emphasized
and encouraged among all staff members and management (Page, 2004). A culture of safety
recognizes that safety is not an accident. It requires all staff to be properly trained and educated
with regard to patient safety and prevention. It requires that the requisite supply of resources and
infrastructure is present and available so staff can function efficiently and effectively within the
workplace.
Where Do We Go from Here?
Despite the many patient safety efforts undertaken since the release of the IOM report,
there is still much work to be done. A recent national survey of consumers highlighted
continuing concerns about patient safety and healthcare quality. Fifty-five percent of those
surveyed reported dissatisfaction with the quality of care received, and 34 percent reported that
14
they or a family member had experienced a medical error (Kaiser Family Foundation, 2004).
There is a perception that healthcare suffers from a culture gap when it comes to safety: “the
healthcare industry is a laggard behind virtually all other sectors of our economy in allowing
unsafe service to proliferate” (Gibson & Singh, 2003, p. xix). More action needs to be taken to
instill a greater sense of confidence in the healthcare system. Healthcare needs to acculturate the
best practices from other industries, such as the nuclear and aviation industry, to best implement
the axiom of “first do no harm.” According to the IOM, an adequate healthcare delivery system
must possess the capabilities to ensure services that are safe, effective, patient-centered, timely,
efficient, and equitable (Institute of Medicine, 2001).
Nurses are committed professionals in a unique role to advocate for patient safety and
contribute to the overall efforts to reform healthcare. Nurses are the largest group of healthcare
providers in the nation and are regarded by the public as the most highly ethical and honest
group of professionals (Moore, 2004). Thus, nurses and the nursing profession play a distinctive
role in promoting positive change that will ultimately benefit patients.
Tools to Improve Safety
One way of improving the quality of care and preventing medical errors is to learn from
medical errors (Leape, 2002). There are several error-reporting tools that can help practitioners
develop a supportive culture of safety, so that they can learn from errors to improve care
delivery. One such tool, from the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), utilizes a voluntary reporting system to capture serious adverse events
(O'Leary, 2000). Serious adverse events are termed “sentinel events” and are defined as “any
unexpected occurrence involving death or serious physical or psychological injury, or the risk
thereof” (Joint Commission on Accreditation of Healthcare Organizations, 2002). The purpose
15
of this type of voluntary reporting is to identify and respond to such events to improve the
quality of care delivered (Joint Commission on Accreditation of Healthcare Organizations,
2002). Healthcare organizations are required to respond to sentinel events and conduct root cause
analysis. The JCAHO developed a framework for conducting root cause analysis to educate and
assist healthcare organizations in analyzing sentinel events (Joint Commission on Accreditation
of Healthcare Organizations, 2005b). Between 1995 and 2004, there were 2,966 sentinel events
reviewed and analyzed by JCAHO (Joint Commission on Accreditation of Healthcare
Organizations, 2005d), and more than 60 percent of sentinel events reported to JCAHO
identified communication as a root cause of the event (Joint Commission on Accreditation of
Healthcare Organizations, 2004).
In addition to the sentinel events program, the JCAHO began requiring compliance with
its National Patient Safety Goals for organizations seeking accreditation, thus ensuring a greater
focus on patient safety. The JCAHO has developed safety goals for ambulatory care, assisted
living, behavioral health, home care, hospitals, and long-term care organizations (Joint
Commission on Accreditation of Healthcare Organizations, 2005c). These goals are reviewed
and revised each year, and apply to various accreditation programs offered by JCAHO. Some of
the 2005 goals include:
•
Improve the accuracy of patient /client/resident identification
•
Improve the effectiveness of communication among caregivers
•
Reduce the risk for healthcare-associated infections (Joint Commission on
Accreditation of Healthcare Organizations, 2005a).
The complete list of safety goals, including the new 2006 Patient Safety Goals are available at
the JCAHO website (www.jcaho.org/accredited+organizations/patient+safety/npsg.htm).
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Another program addressing patient safety is the United States Pharmacopoeia, which
operates the Medication Errors Reporting Program with the Institute for Safe Medication
Practice (ISMP). This program utilizes a voluntary reporting mechanism to track medication
incidents (Institute for Safe Medication Practices, 2005) Through its voluntary approach, this
program promotes a systems approach to medication error analysis, and preventive strategies and
recommendations can be shared with healthcare providers to avoid reoccurrences (Institute for
Safe Medication Practices, 2005).
A safety culture assessment can be a useful tool for improving patient safety, diagnosing the
safety culture of an organization, raising safety awareness, and identifying opportunities for
improvement (Nieva & Sorra, 2003). The IOM recommends “conducting an annual, confidential
survey of nursing and other healthcare workers to assess the extent to which a culture of safety
exists” (Page, 2004, p. 15). The Hospital Survey on Patient Safety Culture measures various
dimensions of the culture, including both hospital and unit level aspects. The unit level aspects
that are measured include:
•
Supervisor/manager expectations and actions promoting safety;
•
Organizational learning—continuous improvement;
•
Teamwork within units;
•
Communication openness;
•
Feedback and communication about error;
•
Nonpunitive response to error; and
•
Staffing (Sorra & Nieva, 2004, p. 3).
This survey, funded by AHRQ, can be found at www.ahrq.gov along with guidance for
administration and reporting the results. There are other initiatives that address the issues of
17
patient safety and error prevention, too numerous to mention here. However, nurses are
encouraged to research the following selected websites to enhance their expertise in patient
safety. (See Patient Safety Websites Table 2)
What Can Nurses Do?
The culture of safety is essential to the efficient, competent delivery of quality care.
Fortunately, there are several nursing organizations that are addressing patient safety issues. One
group is the Center for American Nurses (CAN), which has developed educational material for
nurses discussing the role of the environment in promoting patient safety in its publications;
Transforming Nursing Work Environments to Enhance Safety and Quality: What CMAs and
Nursing Leaders Can Do and The Nation’s Quality Problem and Why Nurses Must Step Up to
the Plate (Greiner). In January 2005, the American Association of Critical-Care Nurses (AACN)
embarked on an ambitious effort to promote patient safety and healthy work environments for
nurses. The AACN developed standards for healthy work environments (American Association
of Critical-Care Nurses, 2005), described in Table 3. These six new standards are congruent
with developing a culture of safety within healthcare environments.
These are just a few of the nursing initiatives that are underway to address the patient
safety problem. Nurses can contribute to the culture of safety by acknowledging deficiencies and
working to resolve them. In one study of medication errors, nurses were noted to be “the ones
most likely to intercept errors” (Leape et al., 1995 p. 37) and responsible for an 86 percent
interception rate of medication errors prior to medication being administered.
The problems facing healthcare are so varied and complex that it will take a multifaceted
approach from nurses and others to solve the problems and improve patient safety. Healthcare
18
environments need to be respectful of all members of the healthcare team, support honest
communication and a culture of safety, and empower all to “do the right thing.”
Table 1: Comparisons of Cultures
Characteristics of a Culture of Safety
Characteristics of a Culture of Blame
Leadership and Support
•
•
The leaders promote a culture of safety (Kohn,
Corrigan, & Donaldson, 2000; Larson, 2000)
Leadership provides the resources needed to promote
patient safety (Institute for Healthcare Improvement,
2005)
•
Leadership not visible in supporting safety
•
Leadership does not provide resources needed to promote
patient safety
Event Analysis
•
Root Cause Analysis approach “what happened, why
did it happen, what to do to prevent from happening
again” (VA National Center for Patient Safety, 2005b)
ƒ
Learn from reported medical errors to prevent
reoccurrence (Leape, 2002)
More reports being generated is perceived positively by
the organization as opportunities to make
improvements in the system are identified (Dotan,
November 2003)
•
Punitive approach to “near misses” and errors (Hughes,
2004)
Reporting
ƒ
ƒ
There is a reluctance to report errors because of fear of
punitive response and suppression of open discussion related
to medical errors (Simpson & Berry, 2001)
Communication
•
•
Effective open communication (Page, 2004)
Recognition of importance of communication and
collaboration among all team players (American
Association of Critical-Care Nurses, 2005)
•
•
•
Emphasis on prevention, not punishment (VA National
Center for Patient Safety, 2005a)
Lack of effective communication
Hierarchical communication (Page, 2004).
Emphasis
•
Emphasis on punishment, not prevention
American Association of Critical-Care Nurses. (2005). AACN Standards for establishing and
sustaining healthy work environments: a journey to excellence. Retrieved January 27,
2005, from
http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandards.pdf
19
Dotan, D. (November 2003). Parallels in aviation and medicine. Unpublished manuscript.
Hughes, R. (2004). First, do no harm. Avoiding the near misses: taking into account one everpresent factor: human fallibility. American Journal of Nursing, 104(5), 81-84.
Institute for Healthcare Improvement. (2005). Develop a culture of safety. Retrieved January 30,
2005, from
http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Develop+a+C
ulture+of+Safety.htm
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (2000). To err is human: Building a safer health
system. Washington, D.C: National Academy Press.
Larson, L. (2000). Ending the culture of blame. Trustee, 53(2), 6-10.
Leape, L. L. (2002). Reporting of adverse events. New England Journal of Medicine, 347, 16331638.
Page, A. (Ed.). (2004). Keeping patients safe: transforming the work environment of nurses.
Washington, D. C: The National Academies Press.
Simpson, K. R., & Berry, M. C. (2001). Second opinion. Should there be mandatory reporting of
medical errors? Writing for the pro position... writing for the con position. MCN:
American Journal of Maternal Child Nursing, 26(3), 120-121.
VA National Center for Patient Safety. (2005a, January 7). Veterans Health Administration:
Creating a Culture of Safety. Retrieved February 13, 2005, from
http://www.patientsafety.gov/vision.html
VA National Center for Patient Safety. (2005b, January 7). Veterans Health Administration:
Root cause analysis (RCA). Retrieved February 5, 2005, from
http://www.patientsafety.gov/rca.html
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Table 2: Selected Patient Safety Websites
Organization
American Nurses Association
Website
www.nursingworld.org
Association of PeriOperative Registered Nurses
www.patientsafetyfirst.org
Agency for Healthcare Research and Quality
www.ahrq.gov
American Association of Critical-Care Nurses
www.aacn.org
Center for American Nurses
www.nursingworld.org/can
Institute for Healthcare Improvement
www.ihi.org
Institute for Safe Medication Practices
www.ismp.org
Joint Commission on Accreditation of Healthcare www.jcaho.org
Organizations
Joint Commission International Center for Patient www.jcipatientsafety.org
Safety
PSNet Patient Safety Network
www.psnet.ahrq.gov
National Center for Patient Safety
www.patientsafety.gov
National Patient Safety Foundation
www.npsf.org
U.S. Food And Drug Administration
www.fda.gov/psn
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Table 3: American Association of Critical-Care Nurses’ Standards for Establishing
and Sustaining Healthy Work Environments*
Standards
1. Skilled Communication
2. True Collaboration
3. Effective Decision Making
4. Appropriate Staffing
5. Meaningful Recognition
6. Authentic Leadership
Nurses must be as proficient in communication skills as they
are in clinical skills.
Nurses must be relentless in pursuing and fostering true
collaboration.
Nurses must be valued and committed partners in making
policy, directing and evaluating clinical care, and leading
organizational operations.
Staffing must ensure the effective match between patient needs
and nurse competencies.
Nurses must be recognized and must recognize others for the
value each brings to the work of the organization.
Nurse leaders must fully embrace the imperative of a healthy
work environment, authentically live it, and engage others in its
achievement.
* Source: American Association of Critical-Care Nurses. (2005). AACN Standards for establishing and sustaining
health work environments: a journey to excellence.
http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandards.pdf
22
References
Agency for Healthcare Research and Quality. (2004). AHRQ's Patient Safety Initiative:
Building Foundations, Reducing Risk An Interim Report to the United States
Committee on Appropriations (No. 4-RG005).
American Association of Critical-Care Nurses. (2005). AACN Standards for establishing
and sustaining healthy work environments: a journey to excellence. Retrieved
January 27, 2005, from
http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandard
s.pdf
Aviation Safety Reporting System. (2004a). ASRS Program Overview. Retrieved
January 30, 2005, from http://asrs.arc.nasa.gov/briefing/br_1.htm
Aviation Safety Reporting System. (2004b). Welcome to Aviation Safety Reporting
System. Retrieved January 30, 2005, from http://asrs.arc.nasa.gov/main_nf.htm
Barach, P., & Small, S. (2000). Reporting and preventing medical mishaps: lessons from
non-medical near miss reporting systems. British Medical Journal, 320, 759-763.
Cohen, M. (2000). Why error reporting systems should be voluntary. British Medical
Journal, 320, 728-729.
Denison, D. (1990). Corporate culture and organizational effectiveness. New York: John
Wiley.
Dotan, D. (November 2003). Parallels in aviation and medicine.Unpublished manuscript.
Federal Aviation Administration. (2001). Fact Sheet- Pilot Flight Time and Rest (October
2001). Retrieved November 14, 2004, from
http://www.faa.gov/newsroom/factsheets/2001/factsheets_0110.htm
Federal Aviation Administration. (2005a, February). 14 CFR Part 121 Subpart Q—Flight
Time Limitations and Rest Requirements: Domestic Operations. Retrieved
February 12, 2005, from http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=dde5252640d3be02bef271588989e05c&rgn=div5&view=text&n
ode=14:2.0.1.4.19&idno=14#14:2.0.1.4.19.17
Federal Aviation Administration. (2005b, February). 14 CFR Part 121 Subpart R—Flight
Time Limitations: Flag Operations. Retrieved February 12, 2005, from
http://ecfr.gpoaccess.gov/cgi/t/text/textidx?c=ecfr&sid=dde5252640d3be02bef271588989e05c&rgn=div5&view=text&n
ode=14:2.0.1.4.19&idno=14#14:2.0.1.4.19.18
Gibson, R., & Singh, J. P. (2003). Wall of Silence the untold story of the medical mistakes
that kill and injure millions of Americans. Washington D.C.: LifeLine Press.
Gold, D., Rogacz, S., Bock, N., Tosteson, T., Baum, M., Speizer, F., & Czeisler, C.
(1992). Rotating shift-work, sleep and accidents related to sleepiness in hospital
nurses. American Journal of Public Health, 82, 1011-1014.
Greiner, A. The nation's quality problem and why nurses must step up to the plate.
Washington, D.C.: Center for American Nurses.
Hecht, M., Jackson, R., & Pitts, M. (2005). Culture: Intersection of intergroup identity
theories. In J. Harwood & H. Giles (Eds.), Intergroup communications: Multiple
perspectives (pp. 21- 42). New York: Peter Lang.
Helmreich, R. L., Musson, D. M., & Sexton, J. B. (2001). Applying aviation safety
initiatives to medicine. Focus on Patient Safety, 4(1), 1-2.
23
Hughes, R. (2004). First, do no harm. Avoiding the near misses: taking into account oneever present factor: human fallibility. American Journal of Nursing, 104(5), 8184.
Hughes, R. G., & Rogers, A. E. (2004). First, do no harm. Are you tired? Sleep
deprivation compromises nurses' health -- and jeopardizes patients. American
Journal of Nursing, 104(3), 36-38.
Institute for Healthcare Improvement. Reduce adverse drug events (ADEs) involving
intravenous medication. Use oral syringes for oral medications only. Retrieved
February 11, 2005, from
http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Individ
ualChanges/Use+Oral+Syringes+for+Oral+Medications+Only.htm
Institute of Medicine. (2001). Crossing the quality chasm a new health system for the
21st century. Washington, D.C.: National Academy Press.
Institute for Safe Medication Practices. (2005). USP-ISMP Medication Errors Reporting
Program (MERP). Retrieved February, 2005, from
http://www.ismp.org/Pages/communications.asp
Joint Commission on Accreditation of Healthcare Organizations. (2002). Sentinel Event
Policy And Procedures Revised: July 2002. Retrieved February 4, 2005, from
http://www.jcaho.org/accredited+organizations/sentinel+event/se_pp.htm#1
Joint Commission on Accreditation of Healthcare Organizations. (2004). Root cause of
all sentinel events (all categories:1995-2004). Retrieved June 9, 2005, from
http://www.jcaho.com/accredited+organizations/ambulatory+care/sentinel+events
/root+causes+of+sentinel+event.htm
Joint Commission on Accreditation of Healthcare Organizations. (2005a). Facts about the
2005 National Patient Safety Goals. Retrieved February 1, 2005, from
http://www.jcaho.org/accredited+organizations/patient+safety/05+npsg/npsg_fact
s.htm
Joint Commission on Accreditation of Healthcare Organizations. (2005b). A Framework
for Conducting a Root Cause Analysis. Retrieved January 21, 2005, from
http://www.jcaho.com/accredited+organizations/ambulatory+care/sentinel+events
/forms+and+tools/framework+.htm
Joint Commission on Accreditation of Healthcare Organizations. (2005c). National
Patient Safety Goals for 2005 and 2004. Retrieved February 8, 2005, from
http://www.jcaho.org/accredited+organizations/patient+safety/npsg.htm
Joint Commission on Accreditation of Healthcare Organizations. (2005d). Sentinel Event
Statistics - December 31, 2004. Retrieved June 9, 2005, from
http://www.jcaho.org/accredited+organizations/sentinel+event/sentinel+event+sta
tistics.htm
Kaiser Family Foundation. (2004). National survey on consumers' experiences with
patient safety and quality information. Retrieved January 10, 2005, from
http://www.kff.org/kaiserpolls/loader.cfm?url=/commonspot/security/getfile.cfm
&PageID=48809
Kohn, L., Corrigan, J., & Donaldson, M. (Eds.). (2000). To err is human: Building a
safer health system. Washington D.C: National Academy Press.
Larson, L. (2000). Ending the culture of blame. A look at why medical errors happen-and what needs to change. Trustee, 53(2), 6-10.
24
Leape, L. (2002). Reporting of adverse events. New England Journal of Medicine, 347,
1633-1638.
Leape, L., Bates, D. W., Cullen, D. J., Cooper, J., Demonaco, H. J., Gallivan, T., et al.
(1995). Systems analysis of adverse drug events. Journal of the American
Medical Association, 274(1), 35-43.
Moore, D., W. (2004, December 4). Nurses top list in honesty and ethics poll. The Gallup
Organization. Retrieved January 20, 2005, from
http://www.gallup.com/poll/content/login.aspx?ci=14236
Nieva, V. F., & Sorra, J. (2003). Safety culture assessment: a tool for improving patient
safety in health care organizations. Quality and Safety in Health Care, 12(Suppl
2), ii17-ii23.
Nightingale, F. (1863). Notes on Hospitals. London: Longman, Green, Longman, Roberts
and Green.
O'Leary, D. (2000). Accreditation's role in reducing medical errors. British Medical
Journal, 320, 727-728.
Osborne, J., Blais, K., & Hayes, J. S. (1999). Nurses' perceptions: when is it a medication
error? Journal of Nursing Administration., 29(4), 33-38.
Page, A. (Ed.). (2004). Keeping patients safe: transforming the work environment of
nurses. Washington, D. C: The National Academies Press.
Paparella, S. (2004). Danger zone. Death by syringe. Journal of Emergency Nursing, 30,
552-555.
Pape, T. (2003). Applying airline safety practices to medication administration.
MEDSURG Nursing, 12(2), 77-93.
Reason, J. (1990). Human Error. Cambridge: Cambridge University Press.
Reason, J. (2000). Human error: models and management. British Medical Journal, 320,
768-770.
Rogers, A. E., Hwang, W. T., Scott, L. D., Aiken, L. H., & Dinges, D. F. (2004). The
working hours of hospital staff nurses and patient safety. Health Affairs, 23(4),
202-212.
Sexton, J. B., Thomas, E. J., & Helmreich, R. L. (2000). Error, stress, and teamwork in
medicine and aviation: cross sectional surveys. British Medical Journal, 320, 745749.
Sorra, J. S., & Nieva, V. F. (2004, September). Hospital Survey on Patient Safety Culture
(prepared by Westat, under Contract No. 290-004) AHRQ Publication No. 040041.Rockville, MD:Agency for Healthcare Research and Quality. Retrieved
February 13, 2005, from http://www.ahrq.gov/qual/hospculture/hospcult.pdf
Uribe, C. L., Schweikhart, S. B., Pathak, D. S., & Marsh, G. B. (2002). Perceived barriers
to medical-error reporting: an exploratory investigation. Journal of Healthcare
Management, 47, 263-279.
VA National Center for Patient Safety. (2005a, January 7). Veteran's Health
Administration: Creating a Culture of Safety. Retrieved February 13, 2005, from
http://www.patientsafety.gov/vision.html
VA National Center for Patient Safety. (2005b, February 1). Veteran's Health
Administration: Triggering Questions for Root Cause Analysis. Retrieved
February 5, 2005, from http://www.patientsafety.gov/Triage/index.html?8
25
VA National Center for Patient Safety. (2005c, January 7). Veterans Health
Administration: Root cause analysis (RCA). Retrieved February 5, 2005, from
http://www.patientsafety.gov/rca.html
VanGeest, J. B., & Cummins, D. S. (2003). An educational needs assessment for
improving patient safety; results of a national study of physicians and nurses.
Chicago, National Patient Safety Foundation. Retrieved January 13, 2005, from
http://www.npsf.org/download/EdNeedsAssess.pdf
Vestal, K. W., & Spreier, S. W. (1997). Facilitating change through cultural assessment.
In J. Lowery (Ed.), Cultureshift a leaders' guide to managing change in health
care. Chicago: American Hospital Publishing Inc.
Wachter, B. (2004, November 30). The end of the beginning: patient safety five years
after "To err is human" Health Affairs (web exclusive), w4 534-545. Retrieved
January 21, 2005, from
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.534v1
Wakefield, D. S., Wakefield, B. J., Borders, T., Uden-Holman, T., Blegen, M., &
Vaughn, T. (1999). Understanding and comparing differences in reported
medication administration error rates. American Journal of Medical Quality,
14(2), 73-80.
Wakefield, D. S., Wakefield, B. J., Uden-Holman, T., Borders, T., Blegen, M., &
Vaughn, T. (1999). Understanding why medication administration errors may not
be reported. American Journal of Medical Quality, 14(2), 81-88.
Woods, A. (2003). Patient safety: not a question of competence. Nursing Management.,
34(9), 6.
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