Patient Safety and Quality care Movement Allison Gosney Student Nurse University of South Florida

Patient Safety and Quality Care Movement Identify concepts related to the Patient Safety and Quality care Movement Discuss components of the movement Discuss the significance of the movement to the professional nurse The purpose of this presentation is to: - identify concepts related to the Patient Safety and Quality Care Movement - Discuss components of the movement - Discuss the significance of the movement to the professional nurse

Patient Safety and Quality Care Movement United States in need of quality improvement in healthcare A 1999 report from the Institute of Medicine displayed the safety gaps in healthcare 2 A 2001 report concluded that the healthcare system failed to provide consistent high-quality medical care to all people 2 As a result, six aims and rules for improvement were proposed Publication of two reports by the Institute of Medicine brought national attention to the need of quality improvement in healthcare. The first report in 1999 displayed the safety gaps in United States healthcare. The report showed that up to 98,000 people died yearly in hospitals as a result of preventable medical errors. The second report in 2001 concluded that the United States’ healthcare system failed to provide consistent high-quality medical care to all people. Due to the results of these reports, the IOM proposed six aims and rules for improvement and redesign of healthcare in the US giving rise to the Patient Safety and Quality Care Movement. The new development and implementation of standardized quality measurement for hospitals led to major improvements using evidence based practices.

Six Aims for Improvement Safety 1 Effective 1 Patient Centered 1 Timely 1 Efficient 1 Equitable 1 The six aims for improvement developed by the IOM include: - Safety: avoiding injuries to patients from the care that is intended to help them. - Effective: Providing evidence based services to all who could benefit. - Patient Centered: Providing care that is respectful of patient preferences, needs, and values, and ensure that patient desires guide all clinical implementations. - Timely: Limiting waits and harmful delays for those who receive and give care. - Efficient: Avoiding waste including, equipment, supplies, ideas, and energy. - Equitable: Providing high-quality care regardless of gender, geographic location, and socioeconomic status. Together these six aims define quality care as proposed by the IOM.

Patient Safety Patient safety is the foundation of the six aims of quality care Patient safety practices have been implemented in hospitals nation-wide to reduce and prevent medical errors and harm to patients 3 Patient Safety is the foundation of the six aims of quality care. A list of patient safety practices have been implemented in hospitals nation-wide to reduce and prevent medical errors and harm to patients. For example, one of these safety practices involves the use of sterile barriers while placing central intravenous catheters to prevent infections.

Types of Safety Errors Communication 3 2. Patient Management 3 3. Clinical Performance 3 The National Quality Forum is an organization who’s mission is to improve the quality of healthcare 4. They have developed a list of three types of safety errors to classify patient safety issues. These three types are: 1. Communication- failing to communicate patient condition and implementations amongst patient, patient proxy, practitioners, nonmedical staff, nurses, and other healthcare team members. 2. Patient Management- improper delegation, failure in tracking, wrong referral, or wrong use of resources. 3. Clinical Performance- Are safety errors occurring Before, during, and after an intervention.

Types of Safety Errors Latent Failure 3 Active failure 3 Organizational System Failure 3 Technical Failure 3 The previous three types of errors can be further classified into latent, active, organizational, and technical failure. Latent Failures: Are errors that are made away from the bedside that affect the patient’s care. These errors may involve decisions affecting organizational procedures and distribution of resources. Active Failures: Are errors that are made in direct contact with the patient. An example of this would be the nurse administering an incorrect dose of a medication. Organizational System Failures: Are indirect errors involving management, protocols, information transfer, and outside resources. An example of this would be understaffing nurses on a unit which increases the chance of error. Technical Failures: Are also indirect errors involving a hospital facility's resources. Such as equipment failure.

Significance of Patient Safety & Quality Care Movement to the Nursing Profession Nurses are directly involved with patient care 3 Communication is critical in nursing to provide quality care and patient safety 3 Nurses delegate tasks to other healthcare team members 3 The field of nursing has been concerned with giving high-quality care and maintaining patient safety long before the Patient Safety & Quality Care Movement. Florence Nightingale, the founder of modern nursing, significantly reduced mortality rates amongst British troops in 1855 by implementing hygiene practices and hand washing. Nurses are directly involved with patient care therefore maintaining and implementing optimum quality care and patient safety is important. Avoiding medication errors and preventing patient falls are just a few of the small ways we keep our patients safe. The most critical element in nursing for us to provide quality care and patient safety is communication. Nurses are a primary communication link in a patient’s care. Practitioners and all other healthcare staff involved in a patient’s care provide us with updates, give orders, and implementations on our patients and we play a key role in communicating all of these updates and implementations amongst the healthcare staff involved with the patient’s care. Nurses also delegate tasks to other team members and it is critical to assess and ensure that these other team members understand and correctly implement the task at hand. A breakdown in communication, patient management, and clinical performance can lead to patient harm and reduced quality care.

Significance of Patient Safety & Quality Care Movement to student It is critical to my patients’ safety that I am able to think critically, maintain clear communication, delegate tasks appropriately, and perform nursing skills to the best of my ability Implement the six aims for improvement to ensure quality care is given 1 The Patient Safety & Quality Care Movement is significant to me as I begin to enter the field of nursing. As I become a nurse it is critical to my patients safety that I am able to think critically, maintain clear communication, delegate tasks appropriately, and perform my various nursing skills to the best of my ability. As a nurse it is also important that I implement the six aims for improvement to ensure quality care is given.

Conclusion Patient safety is the foundation of delivering high- quality healthcare 3 There is still work to be done and continuing research is underway 3 Nurses are at the forefront of patient safety and quality care Patient safety is the foundation of delivering high-quality healthcare. After the IOM initiated the six aims for improvement, patient safety and quality of care have improved however, there is still work to be done and continuing research is underway on developing new ways to ensure patient safety and using evidence based protocols to guide our clinical practice. Since the days of Florence Nightingale, nurses have and still are today at the forefront of patient safety and quality care because of our involvement in direct patient care. By maintaining clear communication, properly managing patient care, and implementing a high clinical performance the incidence of preventable medical errors will continue to reduce.

References Ballard, K. (2003). Patient safety: A shared responsibility. The Online Journal of Issues in Nursing, 8(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodica ls/OJIN/TableofContents/Volume82003/No3Sept2003/PatientSafety.html Chassin, M., O’Kane, M. (2010). History of the quality improvement movement. S. D. Berns (Ed.) , Toward improving the outcome of pregnancy. White Plains, NY: March of Dimes. Mitchell, P., Soule, E. (2008). Defining patient safety and quality care. R. G. Hughes (Ed.) , Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. National Quality Forum (2016). Patient safety. Retrieved from http://www.qualityforum.org/Topics/Safety_pages/Patient_Safety.aspx