patient safety uk essay

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Why patient safety is the whole point of healthcare

• Nursing, midwifery and care
• Patient safety

In 2019, WHO launched the first ever World Patient safety day, a global campaign seeking to raise awareness and bring people together in the pursuit of safer systems, safer culture and safer care for patients. It was great to have a day globally dedicated, where healthcare professionals, patients, service users, families and relatives came together to focus their hearts and minds on safer care, collaboration, doing things right and celebrating the successes and learning when things go wrong.

But of course patient safety is not something that we can focus on for just one day of the year. Since the publication of ’To err is human’ 20 years ago, great progress has been made, yet there is still so much more to do. The NHS has demonstrated a constant desire for enhancing safety delivery, designing safer systems, driving out variation and utilising improvement methodology for sustainable change. It is the constant beat and rhythm of organisations striving for outstanding patient care, that can be heard in the rapid cycle testing of ideas, to understand which interventions will produce improvement and which ones will make care safer.

My passion for patient safety has gained momentum over several years and has culminated in the privileged role of Deputy Chief Nursing Officer, leading the Nursing Safety and Innovation portfolio on behalf of the CNO for England. The portfolio is exciting, covering a range of priorities, and my team is looking to extend our work from focus on providers, to integrated care partnerships, and ultimately across to integrated care systems.

We have seen huge success with the annual national Stop the Pressure campaign and will move this work on this year with the national wound care strategy. We will continue to deliver end of life care, infection prevention and control and acute deterioration with a focus on quality.  And we are leading on new work in clinical sustainability, and the nursing contribution to outpatients transformation and innovation.

We recognise that patient safety cannot be led and delivered in isolation, and to achieve further success in harm prevention, collaboration and multi-professional delivery is key. Therefore, as we embark on delivery of the priorities in the Long Term Plan , we are forging strong professional bonds with safety partners inside and outside the NHS. In addition, the publication of the Patient Safety Strategy in 2019, strengthens our commitment to support the transformation across a number of safety priorities for 2020, whilst reaffirming our safety vision; to continuously improve patient safety.

I recently met with a patient safety leader in the third sector who talked about safety not as activity that we do, but as the core purpose of healthcare. I was struck by this articulate and succinct view and have spent time reflecting on how we could positively exploit this purpose, with our full power.

We need to use intelligence and insight; involve and equip patients, staff and partners with the right skills, to create conditions where improvement methods will flourish and become second nature. This seems very challenging: how do we focus on this when there are so many other competing priorities?

My personal and professional opinion is that if we do not make time to build a strong foundation for safe care, where the culture of patient safety abounds, then we will not build safer systems and we will not improve experience and outcomes for patients. This requires a significant rethink! We will need to work collectively to re-engineer our thinking around safety, and transcend traditional organisational boundaries. We need to re-imagine a system where people are celebrated for their curiosity and creativity, and where identifying system flaws become the norm, and these are actively sought and designed out. And patients and families are our strongest assets! We must make sure they are involved in every step of improvement, and listen to what they have to say to reach the safer future we all dream of. Finally 2020 is the #YearoftheNurseandMidwife . As nurses and midwives, this is our time to shine a light on all that is good about the care we deliver for patients. I look forward to working with colleagues in #teamCNO , and in all of health and care, to make this happen.

Sue Tranka is the Deputy Chief Nursing Officer for Patient Safety and Innovation at NHS England and Improvement.

Sue has 28 years of experience in nursing and has spent the last 21 years working in the National Health service. Sue trained as a midwife, registered general nurse, mental heath and community nurse. Sue’s career spans both operational and clinical leadership roles. Her passion for patient safety and quality improvement culminated in her establishing and leading a Critical Care Outreach team in a North London hospital. Sue‘s nurse consultant and leadership roles have predominantly focussed in the safety arena. Sue has a strong interest in quality improvement, human factors and safety systems.

More recently she has held a Board level role as a Chief Nurse in a provider organisation. Sue currently holds an honorary visiting professor role with University of Surrey and has established a link with Staffordshire University as a professional advisor on Human Factors programme.

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• How to improve...

How to improve healthcare improvement—an essay by Mary Dixon-Woods

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• Mary Dixon-Woods , director
• THIS Institute, Cambridge, UK
• director{at}thisinstitute.cam.ac.uk

As improvement practice and research begin to come of age, Mary Dixon-Woods considers the key areas that need attention if we are to reap their benefits

In the NHS, as in health systems worldwide, patients are exposed to risks of avoidable harm 1 and unwarranted variations in quality. 2 3 4 But too often, problems in the quality and safety of healthcare are merely described, even “admired,” 5 rather than fixed; the effort invested in collecting information (which is essential) is not matched by effort in making improvement. The National Confidential Enquiry into Patient Outcome and Death, for example, has raised many of the same concerns in report after report. 6 Catastrophic degradations of organisations and units have recurred throughout the history of the NHS, with depressingly similar features each time. 7 8 9

More resources are clearly necessary to tackle many of these problems. There is no dispute about the preconditions for high quality, safe care: funding, staff, training, buildings, equipment, and other infrastructure. But quality health services depend not just on structures but on processes. 10 Optimising the use of available resources requires continuous improvement of healthcare processes and systems. 5

The NHS has seen many attempts to stimulate organisations to improve using incentive schemes, ranging from pay for performance (the Quality and Outcomes Framework in primary care, for example) to public reporting (such as annual quality accounts). They have had mixed results, and many have had unintended consequences. 11 12 Wanting to improve is not the same as knowing how to do it.

In response, attention has increasingly turned to a set of approaches known as quality improvement (QI). Though a definition of exactly what counts as a QI approach has escaped consensus, QI is often identified with a set of techniques adapted from industrial settings. They include the US Institute for Healthcare Improvement’s Model for Improvement, which, among other things, combines measurement with tests of small change (plan-do-study-act cycles). 8 Other popular approaches include Lean and Six Sigma. QI can also involve specific interventions intended to improve processes and systems, ranging from checklists and “care bundles” of interventions (a set of evidence based practices intended to be done consistently) through to medicines reconciliation and clinical pathways.

QI has been advocated in healthcare for over 30 years 13 ; policies emphasise the need for QI and QI practice is mandated for many healthcare professionals (including junior doctors). Yet the question, “Does quality improvement actually improve quality?” remains surprisingly difficult to answer. 14 The evidence for the benefits of QI is mixed 14 and generally of poor quality. It is important to resolve this unsatisfactory situation. That will require doing more to bring together the practice and the study of improvement, using research to improve improvement, and thinking beyond effectiveness when considering the study and practice of improvement.

Uniting practice and study

The practice and study of improvement need closer integration. Though QI programmes and interventions may be just as consequential for patient wellbeing as drugs, devices, and other biomedical interventions, research about improvement has often been seen as unnecessary or discretionary, 15 16 particularly by some of its more ardent advocates. This is partly because the challenges faced are urgent, and the solutions seem obvious, so just getting on with it seems the right thing to do.

But, as in many other areas of human activity, QI is pervaded by optimism bias. It is particularly affected by the “lovely baby” syndrome, which happens when formal evaluation is eschewed because something looks so good that it is assumed it must work. Five systematic reviews (published 2010-16) reporting on evaluations of Lean and Six Sigma did not identify a single randomised controlled trial. 17 18 19 20 21 A systematic review of redesigning care processes identified no randomised trials. 22 A systematic review of the application of plan-do-study-act in healthcare identified no randomised trials. 23 A systematic review of several QI methods in surgery identified just one randomised trial. 56

The sobering reality is that some well intentioned, initially plausible improvement efforts fail when subjected to more rigorous evaluation. 24 For instance, a controlled study of a large, well resourced programme that supported a group of NHS hospitals to implement the IHI’s Model for Improvement found no differences in the rate of improvement between participating and control organisations. 25 26 Specific interventions may, similarly, not survive the rigours of systematic testing. An example is a programme to reduce hospital admissions from nursing homes that showed promise in a small study in the US, 27 but a later randomised implementation trial found no effect on admissions or emergency department attendances. 28

Some interventions are probably just not worth the effort and opportunity cost: having nurses wear “do not disturb” tabards during drug rounds, is one example. 29 And some QI efforts, perversely, may cause harm—as happened when a multicomponent intervention was found to be associated with an increase rather than a decrease in surgical site infections. 30

Producing sound evidence for the effectiveness of improvement interventions and programmes is likely to require a multipronged approach. More large scale trials and other rigorous studies, with embedded qualitative inquiry, should be a priority for research funders.

Not every study of improvement needs to be a randomised trial. One valuable but underused strategy involves wrapping evaluation around initiatives that are happening anyway, especially when it is possible to take advantage of natural experiments or design roll-outs. 31 Evaluation of the reorganisation of stroke care in London and Manchester 32 and the study of the Matching Michigan programme to reduce central line infections are good examples. 33 34

It would be impossible to externally evaluate every QI project. Critically important therefore will be increasing the rigour with which QI efforts evaluate themselves, as shown by a recent study of an attempt to improve care of frail older people using a “hospital at home” approach in southwest England. 35 This ingeniously designed study found no effect on outcomes and also showed that context matters.

Despite the potential value of high quality evaluation, QI reports are often weak, 18 with, for example, interventions so poorly reported that reproducibility is frustrated. 36 Recent reporting guidelines may help, 37 but some problems are not straightforward to resolve. In particular, current structures for governance and publishing research are not always well suited to QI, including situations where researchers study programmes they have not themselves initiated. Systematic learning from QI needs to improve, which may require fresh thinking about how best to align the goals of practice and study, and to reconcile the needs of different stakeholders. 38

Using research to improve improvement

Research can help to support the practice of improvement in many ways other than evaluation of its effectiveness. One important role lies in creating assets that can be used to improve practice, such as ways to visualise data, analytical methods, and validated measures that assess the aspects of care that most matter to patients and staff. This kind of work could, for example, help to reduce the current vast number of quality measures—there are more than 1200 indicators of structure and process in perioperative care alone. 39

The study of improvement can also identify how improvement practice can get better. For instance, it has become clear that fidelity to the basic principles of improvement methods is a major problem: plan-do-study-act cycles are crucial to many improvement approaches, yet only 20% of the projects that report using the technique have done so properly. 23 Research has also identified problems in measurement—teams trying to do improvement may struggle with definitions, data collection, and interpretation 40 —indicating that this too requires more investment.

Improvement research is particularly important to help cumulate, synthesise, and scale learning so that practice can move forward without reinventing solutions that already exist or reintroducing things that do not work. Such theorising can be highly practical, 41 helping to clarify the mechanisms through which interventions are likely to work, supporting the optimisation of those interventions, and identifying their most appropriate targets. 42

Research can systematise learning from “positive deviance,” approaches that examine individuals, teams, or organisations that show exceptionally good performance. 43 Positive deviance can be used to identify successful designs for clinical processes that other organisations can apply. 44

Crucially, positive deviance can also help to characterise the features of high performing contexts and ensure that the right lessons are learnt. For example, a distinguishing feature of many high performing organisations, including many currently rated as outstanding by the Care Quality Commission, is that they use structured methods of continuous quality improvement. But studies of high performing settings, such as the Southmead maternity unit in Bristol, indicate that although continuous improvement is key to their success, a specific branded improvement method is not necessary. 45 This and other work shows that not all improvement needs to involve a well defined QI intervention, and not everything requires a discrete project with formal plan-do-study-act cycles.

More broadly, research has shown that QI is just one contributor to improving quality and safety. Organisations in many industries display similar variations to healthcare organisations, including large and persistent differences in performance and productivity between seemingly similar enterprises. 46 Important work, some of it experimental, is beginning to show that it is the quality of their management practices that distinguishes them. 47 These practices include continuous quality improvement as well as skills training, human resources, and operational management, for example. QI without the right contextual support is likely to have limited impact.

Beyond effectiveness

Important as they are, evaluations of the approaches and interventions in individual improvement programmes cannot answer every pertinent question about improvement. 48 Other key questions concern the values and assumptions intrinsic to QI.

Consider the “product dominant” logic in many healthcare improvement efforts, which assumes that one party makes a product and conveys it to a consumer. 49 Paul Batalden, one of the early pioneers of QI in healthcare, proposes that we need instead a “service dominant” logic, which assumes that health is co-produced with patients. 49

More broadly, we must interrogate how problems of quality and safety are identified, defined, and selected for attention by whom, through which power structures, and with what consequences. Why, for instance, is so much attention given to individual professional behaviour when systems are likely to be a more productive focus? 50 Why have quality and safety in mental illness and learning disability received less attention in practice, policy, and research 51 despite high morbidity and mortality and evidence of both serious harm and failures of organisational learning? The concern extends to why the topic of social inequities in healthcare improvement has remained so muted 52 and to the choice of subjects for study. Why is it, for example, that interventions like education and training, which have important roles in quality and safety and are undertaken at vast scale, are often treated as undeserving of evaluation or research?

How QI is organised institutionally also demands attention. It is often conducted as a highly local, almost artisan activity, with each organisation painstakingly working out its own solution for each problem. Much improvement work is conducted by professionals in training, often in the form of small, time limited projects conducted for accreditation. But working in this isolated way means a lack of critical mass to support the right kinds of expertise, such as the technical skill in human factors or ergonomics necessary to engineer a process or devise a safety solution. Having hundreds of organisations all trying to do their own thing also means much waste, and the absence of harmonisation across basic processes introduces inefficiencies and risks. 14

A better approach to the interorganisational nature of health service provision requires solving the “problem of many hands.” 53 We need ways to agree which kinds of sector-wide challenges need standardisation and interoperability; which solutions can be left to local customisation at implementation; and which should be developed entirely locally. 14 Better development of solutions and interventions is likely to require more use of prototyping, modelling and simulation, and testing in different scenarios and under different conditions, 14 ideally through coordinated, large scale efforts that incorporate high quality evaluation.

Finally, an approach that goes beyond effectiveness can also help in recognising the essential role of the professions in healthcare improvement. The past half century has seen a dramatic redefining of the role and status of the healthcare professions in health systems 54 : unprecedented external accountability, oversight, and surveillance are now the norm. But policy makers would do well to recognise how much more can be achieved through professional coalitions of the willing than through too many imposed, compliance focused diktats. Research is now showing how the professions can be hugely important institutional forces for good. 54 55 In particular, the professions have a unique and invaluable role in working as advocates for improvement, creating alliances with patients, providing training and education, contributing expertise and wisdom, coordinating improvement efforts, and giving political voice for problems that need to be solved at system level (such as, for example, equipment design).

Improvement efforts are critical to securing the future of the NHS. But they need an evidence base. Without sound evaluation, patients may be deprived of benefit, resources and energy may be wasted on ineffective QI interventions or on interventions that distribute risks unfairly, and organisations are left unable to make good decisions about trade-offs given their many competing priorities. The study of improvement has an important role in developing an evidence-base and in exploring questions beyond effectiveness alone, and in particular showing the need to establish improvement as a collective endeavour that can benefit from professional leadership.

Mary Dixon-Woods is the Health Foundation professor of healthcare improvement studies and director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety , she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians. This article is based largely on the Harveian oration she gave at the RCP on 18 October 2018, in the year of the college’s 500th anniversary. The oration is available here: http://www.clinmed.rcpjournal.org/content/19/1/47 and the video version here: https://www.rcplondon.ac.uk/events/harveian-oration-and-dinner-2018

This article is one of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

Competing interests: I have read and understood BMJ policy on declaration of interests and a statement is available here: https://www.bmj.com/about-bmj/advisory-panels/editorial-advisory-board/mary-dixonwoods

Provenance and peer review: Commissioned; not externally peer reviewed.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Elliot RA, Camacho E, Jankovic D Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021; 30:(2)96-105 https://doi.org/10.1136/bmjqs-2019-010206

Nursing and Midwifery Council. The code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. 2018. https://tinyurl.com/7upnytyy (accessed 20 October 2021)

Scobie S, Thomson R. Building a memory: preventing harm, reducing harm and improving patient safety. The first report of the National Reporting and Learning System and the Patient Safety Observatory.London: National Patient Safety Agency; 2005

Medication errors: a positive safety culture is key

Editor in Chief, British Journal of Nursing

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Patient safety is an essential part of nursing care; the ultimate aim is to avert avoidable errors and harm to patients. The Nursing and Midwifery Council's (NMC) (2018) Code requires nurses to put the interests of people using or needing nursing services first.

Elliot et al (2021) estimated that each year in England there are 237 million errors at some point in the medication process; nearly three-quarters of these have little or no potential for harm but 66 million are theoretically clinically significant. Avoidable drug errors are estimated to cost the NHS in the region of £98.5 million a year, taking up 181 626 bed days, as well as contributing to 1708 deaths.

Where there are hospital admissions because of medication errors, these are most likely to involve non-steroidal anti-inflammatory drugs (NSAIDs), anti-platelet drugs, epilepsy treatments, drugs used in the treatment of hypoglycaemia, diuretics, inhaled corticosteroids, cardiac glycosides and beta blockers. Most of the resulting deaths (80%) are caused by gastrointestinal bleeds from NSAIDs, aspirin, or the anticoagulant warfarin. Errors occur at every stage of the medicines management process, but over half (54%) are made at the point of administration. Error rates are lowest in primary care, but because of the sector's size, these account for around 4 in 10. Around 1 in 5 medication errors are made in the hospital setting.

The Department of Health and Social Care (DHSC) commissioned a new system to monitor and prevent medication errors. However, all Medicines Safety Improvement Programme activities are currently being reviewed so as to offer support to the national COVID-19 response.

The appropriate allocation of healthcare resources to reduce medication errors requires an understanding of where it is these errors exist and where they are causing the most problem. It is essential to use the data to make links between errors and patient outcomes to progress understanding and reduce harm. In order to create an environment that best promotes shared learning, professional regulators and leaders in the health and care organisations should encourage the reporting of medication errors.

Attempting to prevent errors from occurring in the first instance, and the creation of a culture that actively encourages continuous learning and reflection is advocated. Employer organisations should provide their staff with support so that they are able to uphold the standards in the NMC Code as an important part of providing the quality and safety expected by those who use services.

The medication process will never be error free, but steps need to be taken to reduce harm and support mechanisms must be in place to assist those making errors ( Scobie and Thompson, 2005 ). People make mistakes all the time, not generally because they are incompetent or callous or negligent, but because of the complex systems in which they work. As there are so many possibilities for things to go wrong it is inappropriate for nurses to be punished when they make mistakes. Developing a culture of safety in an organisation and fostering a proactive approach to patient safety can enable meaningful learning to take place when errors have occurred. Increased incident reporting is a strong positive indicator of a good safety culture. Where there are negative attitudes and behaviours these will discourage staff from learning from preventable incidents. In an environment such as this, it is more likely that such incidents will occur again.

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Patient Safety: More than a Promise

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Introduction

In June of 2023, the UK Parliamentary and Health Service Ombudsman released a report summarizing their findings of their review of 22 patient safety incidents that were identified as avoidable deaths, with the aim of highlighting failings in systems and, support learning from the analysis.

The report identified repeated broad themes of clinical failings leading to these deaths and also several factors that contributed to compounded harm experienced by the families of these patients following the deaths of their loved ones.

This podcast is a recording of a webinar, presented by Oonagh Gilvarry, Chief Research Officer at HCI. Oonagh provides a summary of these clinical failings, and the resulting compounded harm, that provide learnings that are applicable across all of the health and social care sectors internationally.

Oonagh Gilvarry

Chief Research Officer

Phone: +353 (0)93 36126

Email: [email protected]

For more information contact  [email protected]  or Phone  +353 (0)1 6292559 .

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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Chapter 1 defining patient safety and quality care.

Pamela H. Mitchell .

Affiliations

• Introduction

The goal of this chapter is to provide some fundamental definitions that link patient safety with health care quality. Evidence is summarized that indicates how nurses are in a key position to improve the quality of health care through patient safety interventions and strategies.

• Quality Care

Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.” 1 Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world. 2 Harteloh 3 reviewed multiple conceptualizations of quality and concluded with a very abstract definition: “Quality [is] an optimal balance between possibilities realised and a framework of norms and values.” This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities).

Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” 4 This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. Theses standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds—death, disease, disability, discomfort, and dissatisfaction 5 —rather than more positive components of quality.

The work of 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: achievement of appropriate self-care, demonstration of health-promoting behaviors, health-related quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs. 6 , 7 The latter indicators were outlined more fully by the National Quality Forum. 8 Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators.

The most recent IOM work to identify the components of quality care for the 21st century is centered on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centered, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built. 9

• Patient Safety

A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient safety was defined by the IOM as “the prevention of harm to patients.” 1 Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients. 1 , 10 The glossary at the AHRQ Patient Safety Network Web site expands upon the definition of prevention of harm: “freedom from accidental or preventable injuries produced by medical care.” 11

Patient safety practices have been defined as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.” 12 This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm. Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows: 12

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
• Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
• Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
• Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding
• Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
• Use of pressure-relieving bedding materials to prevent pressure ulcers
• Use of real-time ultrasound guidance during central line insertion to prevent complications
• Patient self-management for warfarin (Coumadin®) to achieve appropriate outpatient anticoagulation and prevent complications
• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications
• Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections

Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research. 12 Review of evidence to date critical for the practice of nursing can be found in later chapters of this Handbook.

The National Quality Forum attempted to bring clarity and concreteness to the multiple definitions with its report, Standardizing a Patient Safety Taxonomy . 13 This framework and taxonomy defines harm as the impact and severity of a process of care failure: “temporary or permanent impairment of physical or psychological body functions or structure.” Note that this classification refers to the negative outcomes of lack of patient safety; it is not a positive classification of what promotes safety and prevents harm. The origins of the patient safety problem are classified in terms of type (error), communication (failures between patient or patient proxy and practitioners, practitioner and nonmedical staff, or among practitioners), patient management (improper delegation, failure in tracking, wrong referral, or wrong use of resources), and clinical performance (before, during, and after intervention).

The types of errors and harm are further classified regarding domain, or where they occurred across the spectrum of health care providers and settings. The root causes of harm are identified in the following terms: 8

• Latent failure—removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources
• Active failure—direct contact with the patient
• Organizational system failure—indirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors
• Technical failure—indirect failure of facilities or external resources

Finally, a small component of the taxonomy is devoted to prevention or mitigation activities. These mitigation activities can be universal (implemented throughout the organization or health care settings), selective (within certain high-risk areas), or indicated (specific to a clinical or organizational process that has failed or has high potential to fail).

• Nursing As the Key to Improving Quality Through Patient Safety

Nursing has clearly been concerned with defining and measuring quality long before the current national and State-level emphasis on quality improvement. Florence Nightingale analyzed mortality data among British troops in 1855 and accomplished significant reduction in mortality through organizational and hygienic practices. 14 She is also credited with creating the world’s first performance measures of hospitals in 1859. In the 1970s, Wandelt 15 reminded us of the fundamental definitions of quality as characteristics and degrees of excellence, with standards referring to a general agreement of how things should be (to be considered of high quality). About the same time, Lang 16 proposed a quality assurance model that has endured with its foundation of 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 have often viewed nursing’s responsibility in patient safety in narrow aspects of patient care, for example, avoiding medication errors and preventing patient falls. While these dimensions of safety remain important within the nursing purview, the breadth and depth of patient safety and quality improvement are far greater. The most critical contribution of nursing to patient safety, in any setting, is 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. This integrative function is probably a component of the oft-repeated finding that richer staffing (greater percentage of registered nurses to other nursing staff) is associated with fewer complications and lower mortality. 17 While the mechanism of this association is not evident in these correlational studies, many speculate it is related to the roles of professional nurses in integrating care (which includes interception of errors by others—near misses), as well as the monitoring and surveillance that identifies hazards and patient deterioration before they become errors and adverse events. 18 Relatively few studies have had the wealth of process data evident in the RAND study of Medicare mortality before and after implementation of diagnosis-related groups. The RAND study demonstrated lower severity-adjusted mortality related to better nurse and physician cognitive diagnostic and treatment decisions, more effective diagnostic and therapeutic processes, and better nursing surveillance. 19 , 20

Further, when we consider the key role of communication or communication lapses in the commission of error, the role of nursing as a prime communication link in all health care settings becomes evident. The definition of “error chain” at PSNet clearly indicates the role of leadership and communication in the series of events that leads to patient harm. Root-cause analyses of errors provide categories of linked causes, including “(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.” 21 This evidence was used in developing the cause portion of the National Quality Forum’s patient safety taxonomy and is further discussed in other chapters of this book.

Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcomes of care, such as mortality and morbidity. Nurses are critical to the surveillance and coordination that reduce such adverse outcomes. Much work remains to be done in evaluating the impact of nursing care on positive quality indicators, such as appropriate self-care and other measures of improved health status.

• Cite this Page Mitchell PH. Defining Patient Safety and Quality Care. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 1.
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The Role and Importance of Patient Safety Essay

Patient safety interventions are practices aimed at reducing the probability of adverse patient outcomes caused by the health care system. It can be stated that patient safety is the key priority of the health care system (Fitzsimons & Vaughan, 2015). This is because successful interventions in that field can reduce or prevent known harm. Planned local Intervention chosen for weeks 1 and 2 is a thirty-minute pre-discharge medication counseling.

The intervention does not have any potential harms, and the expected benefits include improved medication accuracy, a decrease in the number of unplanned physician visits, and a lower rate of hospital admissions. Pre-discharge medication counseling will be especially helpful for older patients who are prescribed several medications at a time. It is crucial that the implementation of the chosen intervention must be guided by personal and professional values of the staff. This is because such values of healthcare professionals directly influence their clinical decisions and thus patient outcomes. If medical workers value precision and accuracy in caring, responsibility, trust, and human relationship, then it can be expected that intervention will be implemented positively.

The intervention does not violate moral principles, particularly avoiding harm or self-determination. Conversely, pre-discharge medication counseling is aimed at preventing patients from harming themselves by using the prescribed medication inappropriately. Speaking of objections that might be raised, one could mention that the intervention will require additional time from a nurse or a pharmacist and patients might be unwilling to spend their time on counseling. As a result, the number of hours per patient day (HPPD) may slightly increase. However, considering that the intervention has overall positive outcomes, such as better drug knowledge, reduced visits to the doctor and readmissions, it has to be implemented. Above-mentioned objectives can be addressed by making changes in the nursing schedule.

The intervention requires the creation of an action plan, which is a defined program with specific outcomes. The model selected for the implementation of the proposed intervention is Lewin’s Three Stage Change Process Model. The framework is based around a three-step process which allows for applying a high-level approach to the change implementation. The main stages of the given framework are unfreezing, change, and freezing.

The use of Lewin’s Change Model can support health care workers through the transitions and help determine barriers and facilitators to implementation. During the unfreezing stage, the change focus should be identified, specifically, implementing a thirty-minute pre-discharge patient counseling. At this step, the key component is open communication with all stakeholders of the intervention, such as nurses, managers, and administrative staff (Ip, Tenney, A. Chu, P. Chu, & Young, 2018). Possible barriers to implementation may include staff resistance to pre-discharge patient counseling and the lack of trust in the positive outcomes of the intervention. Facilitators to the implementation include support from the upper-level management and incorporation of leadership strategies

During the change stage, implementation of the planned intervention will occur. This will require a sustained effort from all the key stakeholders. Nurse managers will have to redesign nursing schedule with consideration of time spent on thirty-minute counseling. Nurses will have to counsel patients on the use of prescribed medications. Administrative staff will have to create tools to assess the benefits of the intervention. Challenges in this stage may include discovering a need in educational training for nurses and adverse effects on workflow. The process would be facilitated by a nursing leader who could monitor the intervention.

During the final stage of freezing, the change should be stabilized. At this step, barriers are the lack of support from the staff, and facilitators are nursing leaders who promote the change. Resources that are needed for successful implementation of thirty-minute pre-discharge patient counseling are only human ones. However, in order to evaluate the effect of the intervention, data collection and assessment tools should be considered.

Ip, R. N., Tenney, J. W., Chu, A. C., Chu, P. L., & Young, G. W. (2018). Pharmacist clinical interventions and discharge counseling in medical rehabilitation wards in a local hospital: A prospective trial. Geriatrics, 3 (3). Web.

Fitzsimons, J., & Vaughan, D. (2015). Top 10 interventions in paediatric patient safety. Current Treatment Options in Pediatrics, 1 (4), 275-285. Web.

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IvyPanda. (2022, January 21). The Role and Importance of Patient Safety. https://ivypanda.com/essays/the-role-and-importance-of-patient-safety/

"The Role and Importance of Patient Safety." IvyPanda , 21 Jan. 2022, ivypanda.com/essays/the-role-and-importance-of-patient-safety/.

IvyPanda . (2022) 'The Role and Importance of Patient Safety'. 21 January.

IvyPanda . 2022. "The Role and Importance of Patient Safety." January 21, 2022. https://ivypanda.com/essays/the-role-and-importance-of-patient-safety/.

1. IvyPanda . "The Role and Importance of Patient Safety." January 21, 2022. https://ivypanda.com/essays/the-role-and-importance-of-patient-safety/.

Bibliography

IvyPanda . "The Role and Importance of Patient Safety." January 21, 2022. https://ivypanda.com/essays/the-role-and-importance-of-patient-safety/.

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• Health and social care
• National Health Service

NHS Constitution plans to strengthen privacy, dignity and safety

Proposed updates to NHS Constitution for England will reflect biological needs of patients and empower people to request same-sex wards and care.

• Proposed updated NHS Constitution for England would introduce new rapid reviews for patients and better recognise the important role of NHS volunteers
• Putting patients and their families, carers and advocates at the heart of decision making, and strengthening links between NHS services

The privacy, dignity and safety of all patients are to be embedded in how the NHS operates under a new constitution that aims to shape the principles and values of the NHS.  

In the proposed changes to the NHS Constitution for England , patients will be empowered to request that intimate care is carried out by someone of the same biological sex, where reasonably possible.   

An updated NHS Constitution would reinforce the NHS’s commitment to providing single-sex wards. This includes setting out that placing transgender patients in single-room accommodation is permissible under the Equality Act 2010 when it is appropriate, such as respecting a patient’s wish to be in a single-sex ward. 

The government has been clear that biological sex matters. The constitution proposal makes clear what patients can expect from NHS services in meeting their needs, including the different biological needs of the sexes. Illnesses and conditions that we know impact men and women differently should be communicated in a clear and accurate way.   

The consultation also plans to embed the right for patients’ and their loved ones’ access to a rapid review from outside the care team if the patient is deteriorating. The importance of this pledge has been made clear by the tragic story of Martha Mills.

It will run for 8 weeks. The government will consider responses from everyone including patients, the public, staff and NHS organisations, before publishing a response and a new NHS Constitution. 

Health and Social Care Secretary, Victoria Atkins, said:  

We want to make it abundantly clear that if a patient wants same-sex care they should have access to it wherever reasonably possible.   We have always been clear that sex matters and our services should respect that. By putting this in the NHS Constitution we’re highlighting the importance of balancing the rights and needs of all patients to make a healthcare system that is faster, simpler and fairer for all.

Additional updates the government is proposing include:   

• embedding the commitment for patients and their family members in acute and specialist settings to initiate a rapid review of care from outside their initial care team, where the patient’s condition is deteriorating. Not only does this provide a boost to patient safety, but it also puts patients at the heart of their own care
• ensuring the health system works together to understand the needs of different groups within each community and reduce disparities in access, experience and outcomes for all
• strengthening responsibilities on patients to cancel or reschedule appointments and on the NHS to communicate appointment information clearly
• making clear that patients can expect their physical and mental health care to be person-centred, co-ordinated and tailored to their needs
• reinforcing the NHS’s commitment to unpaid carers

Minister for Women’s Health Strategy, Maria Caulfield, said:  

Updating the NHS Constitution is crucial to ensuring the principles underpinning our NHS work for everyone.   This is about putting patients first, giving them the dignity and respect that they deserve when they are at their most vulnerable. Our plans include accommodating requests for same-sex intimate care and respecting single-sex wards.  We’ll also recognise the important role of patients’ loved ones in raising concerns about their care.

The constitution aims to safeguard the principles and values of the NHS. It empowers staff to help improve the care it provides by setting out legal rights for patients and staff when using NHS services. It also sets out clear expectations about the behaviour of both staff and patients, and the role they need to play in supporting the NHS.   

The proposed updates to the constitution will also support the government’s mission to help people to remain in, and return to work, which reflects the important impact that work can have on a person’s health and wellbeing.

Louise Ansari, Chief Executive of Healthwatch England, said: 

The NHS Constitution plays a crucial role in shaping the culture of our NHS and helping the public to know their rights.  Since the NHS Constitution launched, it has helped to shift the balance of power from services towards patients and their families. But, with only a third of people knowing their rights, there is still a long way to go.  Given the challenges our NHS faces, a conversation to reaffirm and raise awareness of the most important rights to the public has never been more timely.  We urge everyone to take part in the consultation and have their say. This is your opportunity to send a clear message about the rights you hold most dear. 

Background information

The NHS Constitution for England was last updated in 2015. It has to be updated at least every 10 years by the Secretary of State. It is a document outlining the rights of patients and staff.

The consultation will be the first stage of a review of the constitution and will run for 8 weeks.

The government will consider responses from everyone, including the public, clinicians and medical professionals, patients, carers and organisations representing patients and staff and health stakeholders, before publishing the consultation response.

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