Patient Safety and Nursing

Nurses are knowledge workers whose main responsibility is to provide safe and effective care within constantly evolving health care systems. Nurses collaborate with one another, as well as doctors, aides and technicians, to provide holistic care to patients. Although advocating for patient safety is a nurse's role, it is also necessary for the patient to be an active participant in their safety. Patient safety is a collaborative goal that requires concerted efforts from the patient and all members of the health care team. It is also a means to foster communication between the patient and the nurse including other health care members to better patient's health.

Nurse's Role
“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2003).

The nursing method is the basis of all clinical judgments and includes all dealings made by nurses in providing care to patients. Considerations for culture, safety, education, health and wellness, patient care, self-health promotion, and planning for long-term health maintenance are included in nursing measures. (Potter et al, 2005).

Recent changes in this profession have:

- Increased the role to provide greater focus on primary care to emphasize prevention and maintenance of health

- A more whole person (including spiritual, physical, and mental components) approach to health care (Potter et al., 2005)

- Including detection and intervention when a breakdown in care occurs in order ɚto reduce adverse effects or events for patients (Ebright, Patterson, Chalko & Render, 2005).

Nurses perform clinical decision-making using the nursing process as a framework. Overall, it is a problem-solving activity focusing on recognizing and defining patient issues and selecting appropriate interventions (Ebright et al., 2005).

Critical Thinking

According to the Ebright et al. (2005), several factors related to safety influence a nurse’s ability to make logical and accurate decisions:

o Knowledge base

o Attention

o Barriers to care (like workplace obstacles)

o Number of tasks

o Missing essential information

o Behaviors not encouraging of productive thought

Complexity of nurse work

Due to the increasingly complex nature of the role of nurses, everyday nursing duties are also a challenge in protecting the safety of every patient. Ebright et al (2005) found the following factors related to safety of delivering patient care:

o Variety of supply locations

o Locating supplies when not found in designated areas or not adequately stocked

o Repetitive travel (to patient’s rooms, nurse’s stations, supply locations, etc.)

o Unexpected situations, interruptions and distractions

o Pauses to wait for system services (computers or medication carts)

o Inadequate resource access for further care and new procedures

o Miscommunication

o Errors due to handwriting and labeling

Patient factors and safety

These are some of the areas of which nurses are responsible for that are significant in ensuring patient safety in a hospital setting:

Nursing Assessments

• Mobility: affects patient’s ability to move independently and control body movement. This includes skin assessment of risk for pressure ulcers and infections of wounds.

• Level of awareness: impairs the patient’s ability to communicate signs of healing or worsening conditions. This relates to how the patient communicates with the nurse and possible interventions related to sedation and lack of consciousness, if applicable

• Critical condition: patients in critical condition require a great deal of care and should be monitored more closely for changes in condition.

• Mental state: those with impaired mental ability will also require more individualized care to provide safety when they are unable to make sound decisions for themselves.

Patient Rights for Medication Administration

• Right patient - nurses should take steps to accurately identify the correct patient to receive medication before administering it.

• Right Medication - nurses should take steps to accurately identify the correct medication to be received before administering it to the patient.

• Right dose - nurses should take steps to accurately identify the correct dosage of medication before administering it to the patient.

• Right Route - nurses should take steps to accurately identify the correct route the patient is to receive the medication before administering it.

• Right Time - nurses should take steps to administer medication in a timely fashion as ordered by the physician.

• Right Documentation - nurses should take steps to accurately document the medication administration after administering it. Hygiene and Cleanliness

• Hand washing - nurses should wash their hands or use a hand sanitizer before and after each patient interaction.

Patient's Role
It is required that nurses and other hospital staff members wash or sanitize their hands upon entering and leaving your room to reduce spread of infection.

Three things patients should ask themselves to ensure their safety while staying at the hospital:

1.)	Why am I at the hospital?

2.)	What is my treatment?

3.)	Why should I have this treatment?

Importance of Questions:

• Patients should always ask questions if they do not understand something.

• The health care team should keep patients informed and educated regarding the patient's care.

• Do not feel scared to the call light.

• Patients can ask for a written form of information including explanations about your procedure, illness, health, etc. For example, you can ask to see your medical records.

Medications:

• The nurses must always check the patient's wrist band before giving medications or treatments.

• Patients should ask questions about the medications they are receiving when they don't understand something.

• Ask if there are any side effects to be aware of.

• Know if the medication will change mental and physical functioning

• Bring a list of home medications: over the counter medications, herbal, vitamins and/or supplements for the health care staff to put in the chart.

Personal Issues:

• Individuals have the right to daily personal cleanliness and clean sheets/blankets.

• Patients should leave any and all valuables such as: wallets, money, jewelry, etc that they do not want lost at home OR request them to be locked up.

• Patients should inform staff of any physical or mental changes, no matter how minor they may be, as soon they occur.

Importance of Plan of Care:

• Patients should know what the plan of care the health care staff have planned for them and if it matches their wishes.

• Cooperation is important to the patient's plan of care.

• Patients should not adjust dressing changes, IV’s, or any type of treatment without consulting the nurse. These regimens have a purpose.

• Patients should follow the plan of care that is recommended after they leave the hospital.

Errors
see Medical error

How do mistakes happen?

In order to prevent errors in health care settings, it may be helpful to understand how those errors occur. One analogy used to explain the error process is called the “Swiss Cheese Model” (Reason, 2000). The idea behind this analogy is that in health care, precautions against errors are put in place like stacks of Swiss cheese, acting as barriers to making mistakes.

However, no barrier is perfect (each piece of Swiss cheese has a few holes it). When an error is able to slip through one of the holes in the barrier that means the safety check has failed. The hope is that if you have a stack of Swiss cheese (in other words multiple safety checks), somewhere along the line that error will run into a dead-end.

It happens occasionally that the error is allowed to pass through each piece of cheese and actually arrive at the patient’s bedside. At this point, a critical error has occurred, which may or may not result in serious injury to the patient. Ultimately this series of small errors lead to one large adverse event (Reason, 2000).

A visual image of the Swiss Cheese Model

How does your level of understanding play a role in your safety?

• According to the Institute of Medicine (2004) almost half of all Americans do not understand the meaning of health terms or how to use the information that is given to them by their health care providers.

• In this country, 46% of adults cannot read and about one-third of senior citizens are either unable to perform or understand instructions given to them by their care providers (Shutan, 2001).

Imagine how this lack of understanding negatively affects that person’s overall health. It has even been shown in studies that not understanding healthcare instructions leads to negative results in terms of their overall health, including a higher rate of surgery and more frequent trips to the emergency room (AHRQ, 2004).

It is important that patients act as active participants in their own health, i.e. always ask questions maintain informed and to understand the plan of care.

Statistics about health care errors

In a group of 22 studies, prescription medication histories included at least one error in 67% of all cases (Tam et al., 2005). Errors in medication history taking can lead to several negative outcomes including life long disability or even death.

Up to 27% of all hospital prescribing errors can be attributed to incomplete medication histories at the time of admission (Tam et al, 2005).

In a recent Institute of Medicine report, it was found that medical errors account for anywhere between 44,000 to 98,000 deaths annually in U.S. hospitals and that 58% of these deaths could have been prevented (IOM, 2000).

A national survey of the American public and practicing physicians revealed that 35% of the physicians surveyed, had made errors related to a patients care (Blendon et al., 2002). 42% of the American public surveyed had experienced an error either in the care of a family member or their own personal health care. One third of the American public surveyed revealed that a health care professional or the physician themselves had either informed them of the error or apologized for the error that had taken place (Blendon et al., 2002).

What is being done to prevent errors?

McFadden et al. (2006), found that the most widespread error reducing method being used in health care organizations to date is the development of blame free error reporting systems. Blame free reporting systems allow hospital employees to report errors for the purpose of correcting hospital policy and procedures. This report also showed that very few hospitals are statistically analyzing the data reported by the hospital employees in order to make corrections within their institution (McFadden, Stock, & Gowen, 2006).

The Institute of Medicine believes that a National Patient Safety Center should be formed to ensure patient safety within health care settings. This organization would be committed to research, tracking, and goal setting. This organization would also work with health care organizations to implement corrections in protocols that have already been identified as problem areas through the use of blame free error reporting systems. A main goal of the Center for Patient Safety would be reducing medical errors by 50%within 5 years (IOM, 2000).

Other methods to improve safety include:

Better lighting and less clutter in work areas where medications are prepared, keeping distractions to a minimum, and keeping noise levels down.

Drug companies and health care facilities are also standardizing medication labels and packaging.

Medications that can have a particularly dangerous effect are being marked as “high alert” (National Quality Forum, 2003).

Many hospitals are investing in technology to minimize errors, such as machines that dispense medications for just one patient at a time.

Patients are given identification bracelets showing their names and allergies.

All medical personnel are required to wear name tags showing their level of training.

Ethics
Also See: Bioethics; Nursing ethics

Dignity

Nurses and health care workers have the responsibility to uphold the dignity and worth of all people they encounter regardless of race, sex, ethnicity,age, religion, beliefs, values, socioeconomic status, and sexual orientation. In addition, it is also the responsibility of patients and their families to mutually respect the dignity of their health care providers and staff. (Munson, 2004)

For example, a nurse caring for an unconscious patient should provide the same or higher level of care as though the patient were conscious. Extra precautions to protect dignity such as speaking respectfully to the patient, covering the patient should be used. Also, informing the patient about care needing to be done prior to initiation acknowledges their dignity.

Autonomy

Allowing the patient to make their own decisions about their care, regardless of the belief of the family members or the health care provider, is very important. Everyone has a right to dictate what care they get at all stages of life.

Informed Consent

Informed consent is a critical aspect of patient rights as well as for protection of the health care providers involved. Patients have the right to refuse any procedure and medication, even if others consider their best interest to receive the care. Respecting this right of the patient is a very important aspect of medical ethics. Requiring written informed consent offers evidence in the court of law that defends the actions of the doctors or nurses involved. There are also protocols that dictate that informed consent must be received before any procedure may be undertaken. (Munson, 2004)

End of life

In order to provide the level of care a patient desires during life threatening and end of life illnesses, nurses and health care providers need to understand their wishes. It is controversial in situations when a health care professional performs procedures or life extending care if the patient clearly desires minimal or comfort measures only.

Advanced Directives

An advance directive is a legal document that a patient signs defining the type of health treatment and care they would like to receive in various health situations that may arise. For example, the directives would describe the kind of care a patient wishes to receive in the event that they contract an illness that they are unlikely to recover from, or if they are permanently unconscious. Different health situations may warrant different directives from the patient.

A living will is a type of advanced directive. It is a legal document that a competent individual freely signs defining the type of medical treatment and care they would like to receive in the event that their health stability should decrease such that they are no longer capable of making important health decisions on their own behalf. A living will does not give anyone else a legal right or responsibility to make health care decisions on the behalf of a patient (Advance directives, 2006).

Without written documentation that expresses the patient's wishes, confusion can occur, leading to errors in providing or withholding the care of the patient. This error may lead to ignoring of patient autonomy.

Truth Telling

Patients may have a right to know the truth from health care professionals about their diagnosis and prognosis. (Munson, 2004)

Scarce Medical Resources

There are limited resources in health care, which present ethical dilemmas for those who work in this field. One aspect of providing ethical care is for nurses and health professionals to avoid duplication and wasteful use of resources. For example, while some medical tests may be needed to provide safe care, multiple tests may be wasteful without providing useful information. However, the cost of safety equipment such as a bed that alarms when the patient is out of bed, or use of pumps to provide medications may be justified by preventing medication errors or falls. (Munson, 2004)

Relevant Applicable Ethical Theories

• Utilitarianism

• Kant

• John Rawls

• Natural Law

Hospital Resources
Hospital Resources and Patient Safety- to engage patients to be actively involved in their health care experience.

1. Ensuring safe medication administration.

Hospitals can provide patients with an up-to-date list of the medications they are receiving. This gives patients more control, and allows for another check for the 5 rights by the person who is actually receiving the drugs. Further, providing patients access to information they can understand about the adverse reactions to the medications they are taking so that they can better identify them if they occur. Providing these resources in different languages if needed.

2. Patient involvement, awareness, and education.

Hospitals provide certain safety mechanisms for patients in the hospital that patients should be aware of. For example, keeping bed rails up, bed/chair alarms, and low beds. Patients should know why and what precautions are in place for their safety. Other examples include patient education about hand washing and infection control and patients marking their own site for surgeries.

3. Understanding their condition.

For example, patients should understand what procedure they had and the expected pain level after analgesic medications have been administered or after non-pharmacological measures have been taken. Knowing this standard, patients can be more active in their pain management.

4. Physical therapy, exercise programs, speech therapy, and occupational therapy.

These services, while helping patients recover, may also evaluate safety needs of patients before being discharged. For example, physical therapists providing information about building strong muscles and bones to prevent falls at home, or speech therapists teaching swallowing techniques to prevent choking. A home evaluate may check home safety. It is the responsibility of nurses to inform patients about these resources and to collaborate with these other disciplines to ensure patient safety.

5. Electronic medical records.

Intranet connects health care workers throughout the hospital concerning the patients electronic medical record (EMR), patient status, allergies, test results etc. to ensure patient safety throughout the hospital. Health care workers are able to access the patient record for better communication of information.

6. Libraries

Hospital libraries are a great resource for patients and health care workers. They are conveniently located in the hospital and provide a wide range of sources, from books and journal articles to the internet.

Current Resources
What is Evidence Based Practice?

Evidence based practice is the use of current evidence from scientific research in order to make health care related decisions. This practice begins much like other scientific processes with a question about health care (delivery of services, types of interventions, etc.) and ends with the data to provide the best possible care to patients’ based upon their individual needs.

Nurse and Evidence Based Practice:

In providing care to patients, nurses must always ask questions about their practice:

• Why am I doing this?

• Why am I doing it this way?

• Is there another better possible way?

Examples of Evidence Based Practice being used:

• For patients who are always lying in hospital beds, research shows that turning them about every 2 hours decreases the amount of pressure on an area, thus lowering the risk of developing a pressure sore or ulcer.

• In repositioning a patient, pillows or foam pads should be used as support devices in order to reduce pressure and protect bony areas (elbows, hips etc.).

• Lifting devices or aids, such as bed sheets, should be used to move patients in bed to decrease the friction.

Summary of how resources effect patient safety

• Patients educate themselves about disease processes, medication, procedures, and new technologies.

• Based on patients’ questions and concerns healthcare professionals take time to reflect on their practice and make changes in plan of care.

• Previous errors inspire/motivate healthcare teams to review and adjust practice for patients’ safety.