EDITORIAL OPINION

Patient Safetyd

Ten Years LaterJan Odom-Forren, PhD, RN, CPAN, FAAN

December 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.