Many people consider quality health care the overarching umbrella under which patient safety exists. The Institute of Medicine (IOM), for example, considers patient security to be “indistinguishable from the delivery of quality health care.” 1 Aristotle and Plato were ancient philosophers who thought about quality and its attributes. One of the great ideas of the Western world was the concept of quality. 2 Harteloh3 examined various definitions of quality. It concluded: “Quality [is] an optimal balance between realized possibilities and a framework of norms and values.” The fact that quality is an abstraction and does not exist as a discrete entity is reflected in this conceptual definition. Instead, it is built through interaction between relevant actors who agree on standards (the norms and values) and components (the possibilities).
Workgroups such as the IOM have attempted to define healthcare quality in terms of standards. The IOM initially defined quality as “the extent to which health services for individuals and populations increase the likelihood of desired health outcomes while remaining consistent with current professional knowledge.” 4 As a result, a definition of quality appeared to be a list of quality indicators, which are expressions of the standards. These standards are not necessarily in terms of the indicators’ possibilities or conceptual clusters. Furthermore, most groups of quality indicators were and frequently still are made up of the 5Ds—death, disease, disability, discomfort, and dissatisfaction5—rather than more positive quality components.
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The American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to criterion. The adverse outcomes of interest were mortality, morbidity, and adverse events, representing the integration of multiple provider inputs. 6, 7 The National Quality Forum elaborated on the latter indicators. 8 The American Academy of Nursing and National Quality Forum quality indicators imply but do not explicitly state safety.
The most recent IOM works to identify the components of quality care for the twenty-first century focuses on conceptual quality rather than measured indicators: quality care is safe, effective, patient-centered, timely, efficient, and equitable. As a result, safety serves as the foundation for all other aspects of quality care. 9
Visit: Patient Safety
The healthcare quality movement has produced an equally abstract definition of patient safety, with various approaches to the more concrete essential components. The IOM defines patient safety as “the prevention of harm to patients.” 1 Emphasis is placed on a care delivery system that (1) prevents errors; (2) learns from errors that do occur; and (3) is based on a safety culture that includes health care professionals, organizations, and patients. 1, 10 The AHRQ Patient Safety Network Web site glossary expands on the definition of harm prevention: “freedom from accidental or preventable injuries caused by medical care.” 11
Patient safety practices are defined as “those that reduce the risk of adverse events associated with medical care exposure across a range of diagnoses or conditions.”
12 This definition is concrete, but it is far from complete because many practices still need to be thoroughly researched regarding their effectiveness in preventing or alleviating harm. The following methods are considered to have sufficient evidence to be included in the category of patient safety practices: 12
Appropriate prophylaxis to prevent venous thromboembolism in at-risk patients
Preventing perioperative morbidity and mortality by using perioperative beta-blockers in appropriate patients.
To prevent infections, use maximum sterile barriers when inserting central intravenous catheters.
Antibiotic prophylaxis is used appropriately in surgical patients to prevent postoperative infections.
To confirm their understanding, ask patients to recall and restate what they were told during the informed-consent process.
Continuous subglottic secretion aspiration to prevent ventilator-associated pneumonia
To prevent pressure ulcers, use pressure-relieving bedding materials.
To avoid complications, use real-time ultrasound guidance during central line insertion.
Warfarin (Coumadin®) patient self-management to achieve appropriate outpatient anticoagulation and avoid complications
Appropriate nutrition provision focuses on early enteral nutrition in critically ill and surgical patients to avoid complications.
To prevent catheter-related infections, use antibiotic-impregnated central venous catheters.
Many patient safety practices, such as the use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as potential strategies to avoid patient safety errors and improve healthcare processes; research has been conducted in these areas, but there are numerous opportunities for further investigation.
12 Later chapters of this Handbook review current evidence critical to nursing practice.
With its report, Standardizing a Patient Safety Taxonomy, the National Quality Forum attempted to bring clarity and concreteness to the various definitions.
13 The impact and severity of a process of care failure are defined as “temporary or permanent impairment of physical or psychological body functions or structure” in this framework and taxonomy. It is important to note that this classification refers to the negative consequences of a lack of patient safety; it is not a classification of what promotes safety and prevents harm. The causes of the patient safety problem are classified by type (error), communication (failures between the patient or patient proxy and practitioners, practitioners and nonmedical staff, or among practitioners), patient management (inadequate delegation, failure in tracking, incorrect referral, or inappropriate use of resources), and clinical performance (before, during, and after intervention).
Errors and harm are further classified based on domain or where they occurred across various health care providers and settings. The following terms are used to identify the root causes of harm:8.
Latent failure—decisions affecting organizational policies, procedures, and resource allocation that are removed from the practitioner.
Direct contact with the patient is an example of operational failure.
Failure of an organizational system—indirect losses involving management, corporate culture, protocols/processes, knowledge transfer, and external factors.
Indirect failure of facilities or external resources due to technical failure
Finally, a small portion of the taxonomy is dedicated to prevention or mitigation efforts. These risk-reduction activities can be universal (implemented throughout the organization or healthcare settings), selective (implemented in specific high-risk areas), or indicated (particular to a clinical or organizational process that has failed or has a high potential to fail).
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Before the current national and state-level emphasis on quality improvement, nursing has been concerned with defining and measuring quality. In 1855, Florence Nightingale examined mortality data among British troops and achieved significant reductions in mortality through organizational and sanitary practices. 14 She is also credited with developing the world’s first hospital performance measures in 1859. Wandelt15 reminded us in the 1970s of the fundamental definitions of quality as characteristics and degrees of excellence, with standards referring to a general agreement on how things should be done (to be considered of high quality). Around the same time, Lang16 proposed a quality assurance model that had stood the test of time due to its foundation in societal and professional values as well as the most current scientific knowledge (two decades before the IOM definition was put forth).
In the past, we often saw nursing’s role in patient safety as limited to specific aspects of patient care, such as avoiding medication errors and preventing patient falls. While these safety aspects are still important within the scope of nursing, the breadth and depth of patient safety and quality improvement are far more significant. The ability to coordinate and integrate the multiple aspects of quality within the care directly provided by nursing and across the care delivered by others in the setting is the most critical contribution of nursing to patient safety in any environment. This integrative function is a component of the frequently stated finding that more affluent staffing (a higher proportion of registered nurses to other nursing staff) is associated with fewer complications and lower mortality. 17 While the mechanism of this association is not precise in these correlational studies, many speculate that it is related to professional nurses’ roles in integrating care (which includes interception of errors made by others—near misses), as well as monitoring and surveillance that detects hazards and patient deterioration before they become errors and adverse events. 18 Few studies have had as much process data as the RAND study of Medicare mortality before and after implementing diagnosis-related groups. The RAND study found that better nurse and physician cognitive diagnostic and treatment decisions, more effective diagnostic and therapeutic processes, and better nursing surveillance resulted in lower severity-adjusted mortality. 19, 20
Furthermore, when we consider the critical role of communication or communication lapses in error commission, the role of nursing as a primary communication link in all healthcare settings becomes clear. PSNet’s definition of “error chain” emphasizes the importance of leadership and communication in the chain of events that leads to patient harm. “(1) failure to follow standard operating procedures, (2) poor leadership, (3) breakdowns in communication or teamwork, (4) overlooking or ignoring individual fallibility, and (5) losing track of objectives,” according to root-cause analyses of errors. 21 This evidence was used to develop the cause portion of the National Quality Forum’s patient safety taxonomy, which is discussed further in other chapters of this book.
Proceed to: Conclusion
Patient safety is the foundation of high-quality healthcare delivery. Much research on patient safety and harm-prevention practices has focused on adverse outcomes, such as mortality and morbidity. Nurses play a critical role in the surveillance and coordination that helps to reduce such adverse effects. Much work needs to be done to assess the impact of nursing care on positive quality indicators such as appropriate self-care and other indicators of improved health status.
How to improve safety and quality in an organization?