The importance of patient safety awareness, by Dr. Pat Patrician

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Patricia A. Patrician, PhD, RN, FAAN

The statistics are grim. Medical errors are the third leading cause of death in this country, affecting between 200,000 and 400,000 patients annually.

Patient Safety Awareness Week, established by the Institute for Healthcare Improvement, serves as a dedicated time and platform to increase awareness about patient safety and to recognize the current work in this area. The goal of patient safety is to minimize risk of harm to both patients and providers through system effectiveness and individual performance.

Health care today is provided within complex, technological settings, but it is still delivered by people and people are not perfect. . Much work has gone into understanding the human factors that lead to error and many we are all too familiar with: clinician fatigue, time pressure, communication challenges, and the rapid advancements in medicine and technology that are sometimes difficult to keep up with.

The IHI website highlights the many forms of safety lapses and errors:

  • “According to a consensus report from the National Academy of Medicine, estimates suggest that 5 percent of U.S. adults who seek care in outpatient settings experience a diagnostic error.
  • The Agency for Healthcare Research and Quality estimates that, at any time, 1 in 31 hospitalized patients has an infection acquired in the health setting.
  • Medication errors and adverse events are among the most common errors in both inpatient and outpatient settings.”

What can we as nurses, and other health care providers, do? The Institute of Medicine (now the National Academy of Medicine) suggested steps to improve patient safety:

  1. Standardize and simplify processes to reduce reliance on memory and vigilance
  2. Train for teamwork because lack of teamwork and communication is a well-known source of error
  3. Involve patients and families in their care so they may spot inconsistencies in their care
  4. Attend to worker safety, which includes scheduling, staffing and fatigue reduction
  5. Implement user-centered design, which includes constraints and forcing functions that make it easier to do the right thing and harder to do the wrong thing. This also includes discouraging work-arounds that often create the environment for errors
  6. Improve access to timely, accurate information at the point of care
  7. Anticipate the unexpected, especially when changing processes. Always ask: What is the worst that can happen?

As nurses and health care providers, it is important to seek out additional information and educate ourselves on improving patient safety. Here are a few resources where you can learn more:

  • Quality and Safety Education for Nurses: qsen.org
  • Agency for Healthcare Research and Quality: ahrq.gov
  • National Quality Forum: nqf.org
  • National Patient Safety Foundation: npsf.org

Patricia A. Patrician, PhD, RN, FAAN, is a Professor and Rachel Z. Booth Endowed Chair in Nursing at UAB School of Nursing. She joined UAB in 2008 after having served 26 years in the U.S. Army Nurse Corps. Her research centers on nursing work environments, nursing care quality, patient safety and other related topics. She teaches in the School’s PhD Program.

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