DNP 835 Topic 1 Discussion Question Two

In this week’s readings, theories of accident causation, human error, foresight, resilience, and system migration were discussed. Identify a safety theory and propose proven quality measures to improve 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

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• 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

  

  DNP 835 Topic 1 Discussion Question Two

• 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).

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