Quality and Safety in Nursing:
Using quality as a tool to
improve practice outcomes
Kim Amer, PhD, RN Associate Professor in
School of Nursing DePaul University
Author of Quality and Safety for
Transformational Nursing Core Competencies
1
Objectives






Identify emerging views of safety and quality in
health care
Describe the current safety crisis and key elements
from the IOM report.
Discuss key questions that need to be considered
when we explore safety in case studies in book.
Identify the types of errors and provide examples.
Discuss the impact of the blame culture and how to
avoid it.
Examine leadership strategies for managing change
in a culture focused on quality
2
Perspectives on quality

What is your definition of safety and
quality?

What are economic consequences?

What are ethical considerations?
3
How does the United States
measure up?
4
Quality carries a moral
and ethical imperative



Nurses are the most trusted profession
People become nurses in order to
relieve suffering and contribute to the
overall health of communities and
individuals
Quality care is an essential value
5
Quality: Factors to consider
– What is the role of technology and informatics
– How do nurses acquire Interdisciplinary team skills to
achieve goals of care
– How do we include patients and families as partners
in care
– What are strategies for improving the way health
professionals must work together to achieve quality
outcomes
6
Raising the Bar: the Framework
All health professionals should be
educated to deliver patient-centered care
as members of an interdisciplinary team,
emphasizing evidence-based practice,
quality improvement approaches, and
informatics.
Committee on Health Professions Education
Institute of Medicine (2003)
7
Emphasis on improving
quality of health care
Focus on quality improvement in
healthcare organizations
Improves patient care outcomes
Helps improve the work environment:
people want to work in organizations
that emphasize quality
8
Quality and Safety Education for
Nurses (QSEN: www.qsen.org)


Principal Investigator: Linda Cronenwett,
Cronenwett, PhD, RN, FAAN
– CoCo-Investigator: Gwen Sherwood, PhD, RN, FAAN
– Project Manager: Denise Hirst,
Hirst, MSN, RN
– Librarian: Jean Blackwell
– National expert panel and pedagogical experts
Funded by the Robert Wood Johnson Foundation for the
University of North Carolina at Chapel Hill
–
–
–
20052005-2007 Phase I PrePre-licensure Education
20072007-2009 Phase II Graduate Education and Pilot School Collaborative
20092009-2012 Phase III Partnered with American Academy of Colleges of Nursing
Nursing
to disseminate information to faculty and educators
Reported in special issue: Nursing Outlook,
Outlook, May 2007
9
New challenges
To achieve the goals of care, health professionals
must examine new views of quality and safety
science for redesigning how care is delivered,
monitored, and improved.
Nurses must be a the table for input.
10
Nurses’ Role Redefined

Continuous quality improvement
– Encourages a culture of inquiry
– Welcomes questions
– Investigates outcomes and critical
incidents from a system perspective
Workers who are engaged in their work ask
critical questions to continually seek to
improve outcomes of care.
11
Quality impacts the work
environment
Nurses who work in hospitals recognized for
quality report healthier work environments
and higher levels of job satisfaction than
those who work in non-recognized settings.
(American Association of CriticalCritical-Care Nurses (AACN), reported in
HealthBeat
)
CQ
Quality is a factor in nurse
satisfaction and retention.
12
6 competencies to transform
systems are not linear but are
broad and overlapping
In fo r
m a ti
cs
lity
Q u a m en t
ove
impr
Patient
centered
care
Evidence
Based
practice
ork
T eam w
An d
r a t io n
c o lla b o
Sa
fe
ty
13
Quality improvement:
Using data to monitor the outcomes of care processes
and using improvement methods to design and test
changes to continuously improve the quality and
safety of health care systems
14
Quality Improvement



Knowledge
– Describe strategies for learning about the outcomes
of care in the setting in which one is engaged in
practice
Skills
– Seek information about outcomes of care for
populations served in care setting
– Seek information about quality improvement projects
in the care setting
Attitudes
– Appreciate that continuous improvement is an
essential part of the daily work of all health
professionals
15
Implications for nursing



Focus on quality and safety requires new
knowledge, skills and attitudes about how
care is delivered, monitored, and improved.
Preparing nurses to work to work in quality
focused settings.
Staff development in quality improvement
processes, safety and error prevention
techniques, and informatics.
16
Developing Quality
Improvement Skills


Knowing the specific steps to interpret integrative
literature reviews to identify the evidence to support
data based care protocols.
Learning new quality improvement terminology such
as variance reports, benchmarks, dashboards, report
cards, statistical control charts, and satisfaction
measures.
17
Quality and Safety: can they
be separated?



Safety science is more than the “5 rights”
rights” of medication
administration, assessing risks for falls, and monitoring
the environment.
It goes beyond individual actions to prevent errors
through system rere-design.
Health care is adapting innovations from the high
performance industries to build cultures of safety by
applying human factors and safety science concepts
18
The Institute of
Medicine
To Err Is Human (1999)
Safety In Healthcare Delivery
Institute of Medicine. (1999). To Err Is Human. Washington, DC:
National Academies Press.
19
A Safety Crisis


The IOM report on safety opened the
door to acknowledge there is a
healthcare safety crisis, for example data
indicated in 1999:
Approximately 44,000 to nearly 100,000
patients die annually in U.S. hospitals
due to error.
What is your reaction to this?
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Discuss this question with the students as an introduction to the topic.
20
Key Terms


Safety: Freedom from accidental injury
Error: Failure of a planned action to be
completed as intended or the use of a
wrong plan to achieve an aim
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Ask students for examples of:
1. Failure of a planned action to be completed as intended
2. The use of a wrong plan to achieve and aim
21
Some Elements of the IOM
Safety Report
Two primary dimensions to consider:
1.
Safe care is consistent with current
knowledge and customized/individualized to
meet patient needs and requirements
2.
Factors within external environment also
have an impact on safety.
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
What do these two elements mean in the clinical setting?
22
Safe Care=Quality Care?
Just because care is considered safe does
not mean that it is of a higher quality.
BUT
There is a greater chance that the care is
of higher quality.
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
How do students respond to this statement?
23
Need for a Framework


To understand more about safety and how
to respond we need a standard framework
and terminology.
We need to know more about the safety
issue.
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Key questions that were considered and should be considered are:
1. How frequently do errors occur?
2. What factors contribute to errors?
3. What are the costs of errors?
4. Are public perceptions of safety in healthcare consistent with the evidence?
24
Types of Errors
1.
2.
3.
4.
Diagnostic
Treatment
Preventive
Other
Many errors go undocumented or are not reported due to
staff fear of reprisal, lack of adequate systems to
report, limited staff education about safety and
report process, and lack of computerized surveillance
systems.
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
1. Error or delay in diagnosis, use of outmoded tests or therapy
2. Error in performance of a procedure, avoidable delay in treatment
3. Failure to provide prophylactic treatment, inadequate monitoring
4. Failure to communicate, equipment failure
25
Errors
26
Patient Role in Errors


Patients make errors in their own care or
during self-management.
Patient noncompliance may lead to errors
(accidental or unintentional non-adherence to
a therapeutic regimen)
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
1. What examples can student give as to how a patient might make an error in selfmanagement?
2. What can the nurse do to decrease the risk of patient error in self-management
of care?
3. How do students feel about noncompliance in patients?
4. What does noncompliance mean?
5. How might students/nurses and patients have different views of treatment?
6. What might be some factors that might lead to non-compliance (ask for specific
examples)?
27
Technology

How might medical technology and
information technology have an impact on
healthcare safety?
What are positive and negative impacts?
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Consider how specific medical technology might affect care, e.g., IV administrations
systems, other automated medication dispensing equipment, etc?
Discuss the importance of training to use equipment, maintenance of equipment,
systems to note when equipment is not working,
Information technology—What systems are available? How do they affect safety?
(computerized documentation/electronic healthcare record (EHR), physician order
entry system (POES), drug order entry system)
Guide the students to discuss the impact of technology on caring.
28
The Blame Culture



What is the Blame Culture?
Why is this important in the IOM report
and its recommendations for change?
How might this be applied to nursing?
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
It is easier to blame an individual for an error; however, most errors are due to
system errors not to individual errors. We need to move away from a punitive
environment.
29
“Building safety into
processes of care is a more
effective way to reduce errors
than blaming individuals.”
(IOM, 1999, p.4)
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
What does this mean? Why is it important?
30
Major Sources of Adverse
Event Data
1.
2.
3.
4.
Voluntary and mandatory reporting
Document review
Automated surveillance
Monitoring patient progress to identify
circumstances when adverse events
might occur
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Students need to understand each of these sources and how nurses are
directly involved in each of these. Discuss with students.
1. What do students think about voluntary and mandatory reporting? As individual?
How it might affect the organization and care?
2. Discuss with students how medical records might be reviewed. Ask students
what areas of the medical record might yield helpful data.
3. What is automated surveillance? What is the student’s reaction to it? How might it
affect staff?
4. What circumstances might be identified?
31
Root Cause Analysis
Definition of Root causes:
causes:
 Specific underlying causes.
 Causes that can reasonably be identified
 Causes management or practitioners have control to fix.
 Causes for which effective recommendations for
preventing recurrences can be made.
Should include:
include: “failed and successful defenses and
recoveries for the patient; outcomes for the patient; and
lessons learned and ways to improve patient safety”
safety”
(IOM, 2004, p. 160).
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Root-cause analysis results should then be explored including: It is important to
recognize that a single root cause is often an oversimplification. “The real purpose
is to use the incident to reveal gaps and inadequacies in the healthcare system”
(Vincent, 2003, p. 1051). The goal should be a systems analysis.
This understanding will lead to greater appreciation of effective safety and system
changes that might be required. Ask students to apply the questions used for
analyzing an adverse event to examples of adverse events, such as an example of
a medication dosage error, a patient fall, wrong site for a procedure.
Identifying root causes is the key to preventing similar recurrences. An added
benefit of an effective RCA is that, over time, the root causes identified across the
population of occurrences can be used to target major opportunities for
improvement.
Root causes are underlying causes. The goal is to identify specific underlying
causes. The more specific that you an be about why an event occurred, the easier it
will be to arrive at recommendations that will prevent recurrence.
Root causes are those that can reasonably be identified. Occurrence analysis
should be cost beneficial.
32
Near-Misses

Errors of commission or omission that could
harm a patient but do not
Think about the times that you almost made an
error. We all have these experiences. What do
you do to learn from these experiences?
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Students need to understand that near misses are very important to report, and they
need to feel comfortable reporting them to their instructors and staff. Reporting of
near misses is a clear indication of the depth of the safety culture in a school of
nursing or in a healthcare organization. Schools of Nursing need to be direct about
this need and explain to students the expectations, for example first report to
instructor and then go through the healthcare organization process. Near misses
are more common in healthcare organizations than is recognized, and more than
likely they are also more common with students. It is also likely that many of the
student near misses go unreported and thus limit what students can learn from
them. As a consequence, students probably experience negative lessons: keeping
secrets, fear of what they might have done and maybe did do, but they do not know
how to analyze the situation, missed opportunity to learn how to prevent an error,
and reinforcement of the process of becoming a staff member who does not report
near misses for fear of results. Near miss data provide information about
weaknesses in the healthcare delivery system and what are the recovery
processes.
HCOs must also be committed to detecting patient injuries and near misses. This
requires that leadership support the effort—developing a culture of safety, providing
resources needed to meet the goals for safety, investing in information
infrastructure to collect data, analyze data, and incorporating decision-making
support systems in the information infrastructure. The organization must incorporate
(1) active surveillance that uses “case finding through real-time, interventional,
prospective data-based clinical trigger systems, as well as retrospective chart
review driven by code-based trigger systems,” (2) routine self-assessments, (3)
standardized, accessible methods for voluntary reporting, and (4) use of
“appropriate protections and rewards for reporting errors and near misses” (IOM,
33
Common Care-Management
Problems





Failure to monitor, observe, or act
Delay in diagnosis
Incorrect assessment of risk
Loss of information during transfer to
other healthcare staff
Failure to note faulty equipment
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Common Care-management Problems
The list on this slide and the following slide are some examples of common caremanagement safety problem concerns. Each one of these is related to nursing care.
As students plan and provide care, these concerns need to be considered in
practica and during content presentation.
34
More Common CareManagement Problems






Failure to carry out preoperative checks
Deviation from an agreed protocol without
clinical justification
Failure to seek help when necessary
Use of incorrect protocol
Treatment given to wrong body site
Wrong treatment plan
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
35
Medication Administration
Recommendations




Use standard processes for medication doses,
dose timing, and dose scales in a given patient
unit.
Standardize prescription writing and prescribing
rules.
Limit the number of different kinds of common
equipment
Implement physician order entry
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Discuss implications of these recommendations from the IOM.
36
Medication Administration
Recommendations





Use pharmaceutical software
Implement unit dosing
Central pharmacy should supply high-risk
intravenous medications
Use special procedures and written
protocols for use of high-risk medications on
patient units
Do not store concentrated solutions of
hazardous medications on patient units
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
37
Medication Administration
Recommendations





Ensure the availability of pharmaceutical decision
support
Include pharmacist during rounds of patient care
units
Make relevant patient information available at the
point of patient care
Adopt a systemsystem-oriented approach to medication
error reduction
Improve patients’
patients’ knowledge about their treatment
(IOM, 1999, pp. 160160-164)
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
38
The call to leadership



To change practice calls for transformational
leadership to achieve the collective purpose
Ordinary methods will not create behavior
change
What is in your tool kit to create new work
environments where quality is valued?
39
5 Essential
Management Strategies





Balancing the tension between
efficiency and reliability
Creating and sustaining trust
Actively managing the process of
change
Involving workers in work design and
work flow decision making
Creating a learning organization
40
Guiding principle…..
 Achieving
quality outcomes is a group
process.
 It
will require all of us working
together in commitment to improve
quality and safety of patient care.
41
Responding to Case Study
In chapters 1-4





Read the case study
Each group will answer one question about the
case
Groups will choose a member to present your
answer and recommendations
Each group will briefly present the group’
group’s answer
and recommendations to the class
You have 20 minutes to discuss
42
EBP and Safety Issues

The AHRQ report, Making Healthcare
Safer: A Critical Analysis of Patient Safety
Practices
http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf
Teaching IOM – Instruction Materials sponsored by the American Nurses Association,
To Err is Human (1999) Safety in Healthcare Delivery
Evidence-based practice and safety issues
The AHRQ report, Making Healthcare Safer: A Critical Analysis of Patient Safety
Practices. (http://www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf), provides extensive
information about evidence-based practice that should be incorporated into nursing
content.
Examples of some of the patient safety practices and targets in the report are:
handwashing compliance, nosocomial infections, central venous catheter insertion,
prevention of surgical site infections, pre-anesthesia checklists, identification
bracelets, prevention of pressure ulcers, pain management, nurse staffing, fatigue
and safety, and much more. Promoting and implementing safety practices are also
discussed and information about practice guidelines, critical pathways, clinical
decision support systems, educational techniques to change provider behavior, and
much more are included in this AHRQ report.
This site is an excellent resource for faculty for teaching and curriculum planning
and for students.
43