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EDITORIAL OPINION
Patient Safetyd
Ten Years LaterJan Odom-Forren, PhD, RN, CPAN, FAANDecember 1, 2009 was the tenth anniversary of To
Err is Human,1 the Institute of Medicine (IOM)
report on medical errors in the health care system.
Dr. Wachter notes that this report “arguably
launched the modern patient-safety movement.”2
Inanupdated analysis,Wachter looks at theprogress
that has been made since that initial report and alsogives an in-depth description of the gaps that are still
present.
How would you grade patient safety progress over
the past ten years? In this article, Wachter looks at
ten domains of patient safety and assigns a grade
representing progress, or lack of progress in the
area. See Box 1.Wachter’s overall grade for progressis a Be, better than the C1 he gave it in 2004.2 You
can read Dr. Wachter’s article for details, but there
were a few important points I want to discuss.
Regulation and Accreditation
When discussing regulation and accreditation is-
sues, Dr. Wachter mentions the importance of the
patient safety goals developed by The Joint Com-
mission after the IOM report. On one hand the pa-
tient safety goals have, for the most part, been on
target and improved the safety of patients. On the
other hand, some goals have been enacted tooquickly without enough evidence to determine
how to accomplish the goal. He notes the best
example as the goal in 2005 requiring hospitals to
The ideas or opinions expressed in this editorial are those
solely of the author and do not necessarily reflect the opinions
of ASPAN, the Journal, or the Publisher.
Jan Odom-Forren, PhD, RN, CPAN, FAAN, is an Assistant
Professor at the University of Kentucky, Lexington, and a
Perianesthesia Nursing Consultant in Louisville, KY.
Address correspondence to Jan Odom-Forren, 800 Eden-
woodCircle, Louisville,KY40243; e-mail address: jodom29373@
aol.com.
� 2010 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
doi:10.1016/j.jopan.2010.06.002
Journal of PeriAnesthesia Nursing, Vol 25, No 4 (August), 2010: pp 209-211
reconcile medication at every patient transition.2
I think we can all identify with what he says about
complex goals or regulations that have been
enacted too quickly.
Other accrediting agencies are addressing the
issues of patient safety now. Examples he includedwere the American Board of Medical Specialties
(ABMS) and the Accreditation Council for Graduate
Medical Education (ACGME) who have under-
scored the importance of new “competencies”
such as systems based practice and have added con-
tent to examinations and educational curricula. I
propose that we also add the Quality and Safety
Education for Nurses (QSEN) effort as an example.QSEN was developed to address the gaps between
the enhanced Essentials of Baccalaureate Educa-
tion for Professional Nursing Practice and the
actual practice of what to teach, how to teach,
and how to assess learning of the patient safety
competencies.3
Wachter does go on to note that a very significantgap exists in accreditation between the standards
for safety required for hospitals and nursing homes
and the lack of stringent requirements for clinics,
physician offices, and surgical centers. Dr.Wachter
gave a grade of B1 compared to his 2004 grade
(after five years) of Ae.2
Health Information Technology
Dr. Wachter gives health IT a grade of C1 com-
pared to his 2004 grade of Be.2 He notes that
health IT is only part of the solution for medical er-
rors, but because the possibility is compelling, the
low adoption is disappointing. Less than 2% of hos-pitals have completely integrated systems with
only 17% having a functioning computerized order
entry.4 Dr. Wachter sees involvement at the federal
level as the most promising development with
$19 billion made available to support health IT
implementation.2
209
Box 1. Domains of Patient Safety
Regulation/accreditation
Reporting systems
Health information technology
Malpractice systems and accountability
Workforce and training issuesResearch
Patient engagement and involvement
Provider organization leadership engagement
National and international organizational
interventions
Payment system interventions
Data from Reference 2
210 JAN ODOM-FORREN
The Malpractice System andAccountability
First, Dr. Wachter notes that there has been no
change in the U.S. tort system, but then goes onto discuss the positive strides in accountability
that have occurred.2 He talks about the importance
of changing the culture of blame that was present
in 1999 to one that promotes a look at systems
that allowed errors to occur. Now he believes
that we have matured to the point that we need
to begin to hold individuals accountable for failing
to adhere to safety processes. He distinguishes be-tween “human error” defined as “inadvertent slips
by good workers” which should be managed with
“no blame” and a systems failure approach versus
“blameworthy acts” such as “conscious disregard
of unreasonable risks” that should be managed
with remedial or punitive action.2 His examples
of failure to follow an accepted practice are hand
hygiene and the time-out before surgery.5 He givesthis area a grade of C1, an improvement from aD1in 2004, and points out that the future focus should
be on striking a crucial balance between “no
blame” (systems thinking) and accountability.2
Research in Patient Safety
Themost important result of research in the area of
patient safety has been the emergence of a model
that promotes themeasurement of an all or nothing
approach to multistep safety practices.2 The multi-
step procedure, such as that demonstrated by de-
creased central line infections is called a practicebundle. The concept of a checklist grew out of
this model as a way to facilitate adherence to all
aspects of the practice bundle. Wachter cautions
that some practices have been accepted and put
into practice before research has established
effectiveness of the practice. The examples he
uses are medication reconciliation (Joint Commis-sion), inclusion of bedsores and falls in Medicare’s
no pay for errors program, and the Rapid Response
Team (promoted by the Institute for Health care
Improvement.)2 Wachter gives research in patient
safety a Be (it was not graded in 2004) because
even though there has been some progress, we still
have limited funding available, gaps in knowledge,
and an ongoing debate as to the importance of ro-bust evidence before institution of new practices.
Interventions by National andInternational Organizations
The increased activity of organizations focusing on
patient safety was the reason for this new category
receiving an Ae from Wachter. The Joint Commis-
sion makes unannounced visits, the Agency for
Health care Research andQuality (AHRQ) supportsa number of initiatives in safety, the World Health
Organization supports quality improvement and
safety initiatives internationally (including the
checklist studies), and physician and nurse accred-
iting agencies are adding safety as a core compe-
tency. The National Quality Forum with its list of
“never events” and the Institute for Health care
Improvement with two campaigns that have savedlives have made progress over the past ten years.
I would like to add the importance of the safety ini-
tiatives of the Surgical Care Improvement Project
(SCIP) and the Council on Surgical and Periopera-
tive Safety (CSPS) teams. ASPANhas been an impor-
tant player in developing safety practiceswith both
of these groups. The only concern about all these
various organizations developing and implementingstandards in the practice setting is the fear that
health care organizations will be overwhelmed by
too many competing requirements. Dr. Wachter
calls for harmonization to prevent this from happen-
ing.2 I believe that as a specialty organization we are
called to contribute our expertise within our spe-
cialty arena and in the bigger picture nationally and
internationally to increase thequality of patient care.
What Does This Mean to Us asPerianesthesia Nurses?
I have focused on a few selected domains of
patient safety to try to point out the gains that
EDITORIAL OPINION 211
have occurred over the past ten years and the
gaps that need to be closed as we move forward.
It is imperative that ASPAN as an organization and
perianesthesia nurses as individuals continue
their quest for safe patient care. We must makesure that we sit at local, state, national, and inter-
national tables where the discussions occur. We
also must strive to support efforts that bring
accountability to the forefront. For example, it
is inexcusable for us to have a 60% hand hygiene
rate in a health care facility that has addressed all
system issues and implemented gel in every room
or at every patient station. We also must support
research that focuses on patient safety in the
perianesthesia setting. Overall, there has been
much progress since 1999. I would like to endon a positive note with a quote by Dr. Wachter
who says, “We should take some pride in the
progress we have made in patient safety, progress
that reflects enormous commitments of time and
passion by caregivers, leaders, and health care
organizations.”2
References
1. KohnLT, Corrigan JM,DonaldsonMS, eds.ToErr isHuman:
Building a Safer Health System. Washington, DC: National
Academies Press; 1999.
2. Wachter RM. Patient safety at ten: Unmistakable progress,
troubling gaps. Health Affairs. 2010;29:165-173.
3. Cronenwett L, SherwoodG, Barnsteiner J, et al.Quality and
safety education for nurses. Nurs Outlook. 2007;55:122-131.
4. Jha AK, DesRoches CM, Campbell EG, et al. Use of elec-
tronic health records in U.S. hospitals. N Engl J Med. 2009;
360:1628-1638.
5. Staff. Patient safety at 10 years: How far have we come?
What’s next? OR Manager. 2010;26:5-7.
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