In May 2001 my 80 year old father entered a community hospital in Pennsylvania for an aortic valve repair and a coronary bypass graft. Leading up to this event were a series of echocardiograms which showed increasing aortic regurgitation; and my dad was finding it increasingly difficult to walk distances without fatigue.
I was scared to death for my dad, not because I didn’t think he could weather the surgery — he’s a vibrant octogenarian who remains active in his community and loves life. What worried me most was his impending nursing care. Would he have nurses sufficient in number and experience to care for him? Would they be there if and when he needed them? Would he have a positive patient outcome?
In fact, he needed those nurses. In his 5-day hospital post-op recovery period, he experienced three third-degree heart block episodes that culminated in a permanent pacemaker insertion. In all three events, his nurses were there, diagnosing the event, taking measures to correct the dysrhythmia, and providing reassurance. I am convinced that his outcome was immeasurably improved because of the care he received.
Patient safety is what this topic is about. Safety lies at the crux of the care we deliver. And yet we all know that there are so many factors that affect patient safety — from communication snafus through systems design problems through inadequate staffing — at the minimum. Nurses are in pivotal roles within health care settings because they coordinate, implement, and evaluate the patient care that is administered by the entire team on an ongoing basis.
All of us personally want safe health care, and most assuredly we want to make certain that our patients have safe care. However, the current lexicon sometimes uses the terms "safe" interchangeably with "quality." The two adjectives are similar, but not identical. "Safe" care is care administered without errors that have a negative impact on the patient’s well being. Safe care has objective parameters.
"Quality" care, on the other hand, connotes excellence, the highest standard. Quality care is subjective by nature. Patients might believe they have quality care if they receive their meals on time. Direct-care nurses might believe that their patients receive quality care if they get their medicines and treatments on time, in addition to individual one-on-one interaction time with their patients. Others might believe that quality care is delivered if it conforms to established pathways or guidelines.
Within this topic the reader may see instances in which quality and safety are used interchangeably. Nevertheless, the emphasis is on safety, which is the sine qua non, the absolute prerequisite and goal to which all of us must work as we improve our health care delivery system.
This topic contains a comprehensive review of the safety-in-health-care challenges before us. Readers should be able to differentiate among the various national public and private entities involved in the safety movement, review the evidence-base for error reduction and the impact of nurse staffing on patient outcomes, understand the complex legalities underpinning real reform in prevention of errors, and examine the role of the professional association in setting standards for safe delivery of nursing care.
Through a historical prism, Quigley discusses the challenges healthcare organizations face as they work to reduce errors and provide safe patient care. In her review, Quigley outlines the American Nurses Association’s (ANA) role in identifying and collecting data on nursing quality indicators. She discusses the seminal report by the Institute of Medicine (IOM), To Err Is Human (1999), which cited that as many as 98,000 deaths per year in the U.S. may be due to medical errors. The report lent momentum to the current patient safety initiatives. Since the IOM report, a variety of private, state, and national entities have become involved in the reducing medical errors. Quigley reviews each of these, including The Leapfrog Group, the Quality Interagency Coordination Task Force, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Finally, Quigley discusses the nursing role in meeting the new JCAHO safety standards for hospitals.
Keepnews and Mitchell address the legal complexities associated with error reduction and patient safety. The IOM (1999) report, To Err Is Human, indicated that creating substantive error reduction in health care meant changing the "culture of blame" to a "culture of safety." In the culture of blame, a nurse administering a medication incorrectly is blamed for the error and punitive or remedial action is taken against her/him. In the culture of safety the emphasis is on systems failures as the root of errors. Consequently, the focus in a culture of safety is not only to conduct a root cause analysis but also to figure out and implement strategies that focus on preventing future errors. Unfortunately, the tort system is based on finding redress for grievances usually through attaching blame on an individual. Keepnews and Mitchell discuss the challenges associated with preventing error through fear of litigation as opposed to studying errors from a systemic perspective and correcting the processes involved in creating the error. They conclude with a discussion on ways to create a culture of safety within the environment notwithstanding the legal obstacles.
Rowell analyzes the manner in which the professional association functions to safeguard the public through creating a code of ethics, standards, and policies that govern the practice of nursing. Rowell refers to the role of society and its relationship to nursing. She reviews the documents that serve as the foundation for practice—Nursing: Scope and Standards of Practice (ANA, 2003a), the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001), and Nursing’s Social Policy Statement (ANA, 2003b). Professional associations are the advocates for the discipline and for those whom they serve. As such, they define the parameters of nursing practice for safe care and increasingly help to identify markers of safe care.
Ballard identifies and describes the responsibilities of the various stakeholders involved in safe patient care. These include society, patients, nurses, physicians, policymakers, professional societies, accrediting agencies, and other national entities. Ballard describes how society, i.e., people, norms, cultures, and institutions all play roles in patient safety, and clearly society involves the diverse competing factors which affect the culture and climate for patient safety. Patients have a role in affecting safety of their care through education and the consumer movement. Nurses and physicians have individual responsibilities to be safe competent practitioners. More than that, they must be involved in working collaboratively to sort out systemic and professional issues affecting safe care. Policymakers influence patient care outcomes with legislation, such as that designed to create error reporting systems and change the work environment. Professional societies develop practice standards and guidelines and codes of ethics that underpin the education, and practice of the members of their discipline. Accrediting agencies, such as JCAHO, set safety standards and goals. Finally, national entities, such as the National Committee for Quality Assurance, develop tools for evaluating systems and processes that relate to quality care.
Curtin concludes the initial articles in this series as she synthesizes research that links nurse staffing to patient outcomes. She begins her synthesis by referring to Nightingale’s work that demonstrated the relationship between soldiers’ deaths and unsanitary conditions at the hospital in Scutari and the effects of sanitary reforms on reducing mortality rates. Curtin’s synthesis of the most recent research (within the past decade) indicates that nurse staffing is integrally involved with patient outcomes. However, like Nightingale’s work, which identified systemic causes for adverse outcomes, Curtin discusses other factors besides staffing that are related to positive patient outcomes. These include organizational characteristics and collaborative relationships among nurses and physicians. Curtin concludes that nurse staffing is important, but not in and of itself, and that administrators must meet the staffing challenge while working on other systemic issues.
My hope is that all people will be the recipients of safe nursing care that leads to quality outcomes. For my father, his nurses spelled the difference between life and death. I am thankful everyday for their presence in his recovery.
We hope that you will learn from these articles. We also encourage you to submit manuscripts in this area so that we can continue to advance our understanding of this important topic.
Rebecca B. Rice, RN, EdD, MPH
Becky Rice is employed as a legislative coordinator at Virginia Law and Government Affairs, PC, a law/lobbying firm in Richmond, VA (www.vlga.com), where she is honing her skills as a patient advocate and lobbyist for a variety of health-related organizations. She continues to be actively involved in state nursing workforce issues, having most recently managed the day-to-day activities of Colleagues in Caring: Regional Collaboratives for Nursing Workforce Development, a national program funded by The Robert Wood Johnson Foundation. Her interest in patient safety issues stems from her two-fold passion—serving as patient and nurse advocate—wanting the safest care possible for patients and working to assure that nurses are involved in systematic resolution of medical errors. Her expertise lies in coalition building, policy analysis, and information brokering.
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.
American Nurses Association. (2003a). Nursing: Scope and standards of practice. Washington, DC: American Nurses Publishing. [Available late October 2003].
American Nurses Association. (2003b). Nursing's social policy statement 2003. Washington, DC: American Nurses Publishing.
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.