Hospital leaders know the steps they need to take to reduce errors—the hard part is ensuring those steps are taken every time.
 |
| Deborah M. Nadzam |
Are we still talking about how to make patient care safer in 2007? Yes, and we always will be. Patient safety is not a fad. It’s what health professionals do every day to take care of those who need counsel, cure or care.
Now more than ever, patient safety is a critical issue facing health systems. Today, one in 10 patients around the world is affected by a medical error, and in the United States, more people die from medical errors than from traffic accidents, breast cancer or HIV/AIDS.
Patient safety must remain front and center for health care professionals, as evidenced by the nine recommendations issued by the World Health Organization’s Collaborating Centre for Patient Safety Solutions. These recommendations focus on steps every institution can take to improve patient safety. (See figure 1, “Nine Solutions for Patient Safety,” below.)
While most health care professionals agree that such evidence-based practices help minimize risks to patients, they face significant challenges. For example, everyone in a health care setting understands the benefits of reconciling a patient’s medications upon admission, between transfers and at discharge. Yet designing and implementing the steps to accomplish those tasks has been extremely difficult for most hospitals.
In another example—wrong-site surgeries—the protocol outlines clear, simple actions that, if taken, will prevent errors. Yet something is getting in the way with completing all of these actions all of the time because adverse events keep occurring.
Why is it so difficult to implement safe practices? One reason is the nature of the practice and its existence within a complex system. But perhaps another reason is the loose connections within the organization—connections between leaders, clinicians and patients. The emphasis of many national patient safety goals and safe practices has been on clinical systems and clinician behaviors: Prescribe the right drugs, implement clinical care bundles and repeat the spoken order or critical test result. These are critically important, evidence-based practices that should be fully embraced and implemented. Health care professionals need the support and backing of the organization’s leaders and board to practice safely and prevent harm to patients.
Three Areas of Concern
Within all institutions are three specific areas that drastically impact patient safety: medication safety, infection prevention and control, and environment of care. These areas require leaders’ attention to eliminate risks and prevent harm to patients.
Medication safety. Communication plays a central role in medication errors. Some of the more common causes of medication errors include confusing two similar drug names (soundalike/look-alike drugs), illegible writing, improper use of high-risk medications, and overdependence on technology that aims to improve medication management but often prompts new types of errors. Up to 46 percent of these errors occur when new orders are written at patient admission or discharge. Better discussion among providers at transition of care will help ensure there is absolute clarity on the patient’s treatment. Leaders must encourage and support all clinicians involved in the medication management system to double-check and respectfully challenge each other when any doubt exists concerning medication use.
Infection prevention and control. Globally, 1.4 million patients who enter the hospital each year end up even sicker because they acquire an infection. Leaders should conduct a thorough examination of their institutions’ infection prevention infrastructure as well as use of evidence-based infection control practices, then compare findings with industry standards. Specifically, the institution should introduce an infection prevention and control committee, oversee surveillance methodology, apply infection control data to practice and performance improvement, and promote environment of care and infection control models for risk assessment. Subsequent improvement will go a long way toward lessening the risk of infection.
Environment of care. Today’s pressures of pandemic disease outbreaks, threats of bioterrorism and new strains of drug-resistant organisms emphasize the importance of a well-designed and up-to-date environment. Health settings must remain on top of individual precautionary safeguards—from ensuring emergency department security to equipping rooms for potential infectious disease outbreaks.
The key to meeting these new demands in an environment of care is planning. Preparing for a worst-case scenario, while it may be time-consuming, pays off in both the short and long term. The analysis of the environment and conclusions about its strengths and weaknesses spotlight those small changes that can be addressed with a simple change of procedure. At the same time, preparing for extreme situations gives leaders a grasp of the resources needed to develop the protocol for a worst-case scenario and allows time to budget for and introduce new safeguards accordingly. Such forethought will go a long way not only toward preparing for the future, but also toward creating a safer environment now. (See figure 2, “Questions to Consider about Patient Safety in Your Organization,” below.)
Implementing Change
Medication management, infection prevention and control, and the environment of care are critical elements of patient safety. While the World Health Organization’s Collaborating Centre has devised excellent recommendations for standardizing patient safety, it is up to the individual health organization to outline the specific procedures and processes that fit its unique environment.
Board members, executive leaders, clinicians, patients and families—each is a major contributor to safety. Implementing safe practices focused on patient involvement, culture and board participation is the key to making health care safer. Building stronger connections throughout the health care organization requires the engagement of all. We must connect the dots among everyone involved in health care if we hope to realize patient safety to its fullest extent.
Deborah Nadzam, Ph.D., F.A.A.N., is the practice leader for patient safety at Joint Commission Resources Inc. and Joint Commission International in Oakbrook, Ill. She has more than 30 years’ experience as a health care practitioner, educator, administrator and researcher.
Figure 1: Nine Solutions for Patient Safety
The Joint Commission and Joint Commission International have been designated as the World Health Organization’s Collaborating Centre for Patient Safety. The nine solutions developed by the Centre are:
1. Avoid patient identity confusion by involving the patient in the process, standardizing identification methods internationally and instituting protocols for distinguishing patients of the same name.
2. Lessen hand-over mistakes by communicating critical information more thoroughly.
3. Prevent incorrect surgery by instituting a preoperative verification process.
4. Verify concentrated electrolyte solutions by identifying them clearly and by standardizing dosing, units of measure and terminology.
5. Avoid catheter and tubing misconnections, emphasizing meticulous attention to detail when administering medications and feedings and when connecting devices to patients.
6. Ensure single use of injection devices and proper disposal.
7. Encourage improved hand hygiene to prevent health care-associated infection.
8. Ensure medication accuracy at transitions with thorough communication during all steps of care.
9. Distinguish look-alike, soundalike medications by ensuring that prescriptions are legible and by using preprinted orders or electronic prescribing.
(Source: World Health Organization’s Collaborating Centre for Patient Safety, 2007)
Figure 2: Questions to Consider about Patient Safety in Your Organization
Organizational leaders:
- Is patient safety a top priority for the organization?
- Are staff comfortable reporting near misses and adverse events as well as sharing stories and ideas that will minimize risk to the patient?
- Is the organization’s patient safety program limited to implementation of each safe practice in a silo fashion, or are mindfulness and vigilance being promoted across all settings, specialties and departments?
- Are leaders actively pursuing issues of safety by making rounds and talking with front-line staff?
The board:
- How aware and involved is your board? Is patient safety a standing agenda item?
- Is the board driving and supporting the successful implementation of safe practices?
- Are any board members accompanying executive leaders on walkarounds to talk with front-line staff?
Patients:
- Are there specific actions you can encourage patients and families to take to advance safe practices? For example, does preoperative education material tell the patient to expect site markings and time-outs?
- We can’t ensure that all patients digest this material, so why not give them every opportunity to participate more actively in their care? It’s a potential opportunity to prevent an error.
GIVE US YOUR COMMENTS!
Hospitals & Health Networks welcomes your comment on this article. E-mail your comments to hhn@healthforum.com, fax them to H&HN Editor at (312) 422-4500, or mail them to Editor, Hospitals & Health Networks, Health Forum, One North Franklin, Chicago, IL 60606.
If you would like a FREE Subscription to H&HN OnLine, please click here to register.