The laboratory is a key partner in assuring patient safety

Medical errors have a great impact on patient outcomes. They can cause serious injury to patients or even result in their deaths. However, morbidity and mortality can sometimes be prevented by the timely and effective action of health care workers. Several IOM Reports have focused on the problem of errors in the United States health care system and identified gaps that need to be addressed. As part of the overall health care system, clinical laboratories are vulnerable to medical errors. Because of significant efforts on the part of both the laboratories and the manufacturers of laboratory equipment and reagents, the errors in the analytic phase of the total testing process now represent the smallest portion of testing errors. Currently, laboratory testing errors occur most frequently in the preanalytic phase. The primary reason for the high prevalence of preanalytic errors is that, at the present time, it is difficult to monitor all preanalytic variables and to implement necessary improvement processes, particularly when some of the variables (like phlebotomy) are not under the control of the laboratory. Considerable efforts have been made by laboratory professionals and other stakeholders to decrease testing errors. Minimal quality requirements have been set through regulations for both laboratory testing and the manufacture of medical equipment and reagents. At the same time, nonregulatory approaches have greatly affected the quality of laboratory testing. These include laboratory standards, various quality improvement programs, voluntary reporting of adverse events, and, in the near future, the National Report on the Quality of Laboratory Services. The introduction of successful approaches from other industries, such as Six Sigma and Lean, also will help reduce the rate of laboratory errors. The clinical laboratory has done more than most other sectors of health care to decrease the occurrence of medical errors, making it a key partner inpatient safety.     

Patient safety, errors and mistakes, and perioperative nursing

Today's world of advancing technology in health care represents complex diagnostic, operational, and administrative processes, all of which must be coordinated to ensure the delivery of safe, quality health care. Nonetheless, the health care industry's implementation and practice of quality measures fall below the standards of other industries, such as aerospace, telecommunications, or information technology. With health care performing at this lower level, it is no wonder that headline grabbers dwell on the deaths that occur as a result of medical errors. A new emphasis on quality management is essential in nursing education and in quality management to improve US health care. This article summarizes recent reports on medical errors and suggests strategies to improve patient safety.     

Changing competencies in health care professions: Will your nurses be ready?

In 1999, the Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” brought the issues of medical error and patient safety to the forefront of national concern.¹ In this report, the now popularized statistic that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented” stimulated health care providers and purchasers into action. Problems arising from decentralized and fragmented delivery systems, inadequate safety reporting methods, and the absence of a blameless culture of learning in health care all were cited as contributing factors to preventable medical errors with resultant patient harm.     

Medical errors: overcoming the challenges

The issue of medical errors has received substantial attention in recent years. The Institute of Medicine (IOM) report released in 1999 has several implications for health care systems in all disciplines of medicine. Notwithstanding the plethora of available information on the subject, little, by way of substantive action, is done toward medical error reduction. A principal reason for this may be the stigma associated with medical errors. An educational program with a practical, informed, and longitudinal approach offers realistic solutions toward this end. Effective reporting systems need to be developed as a medium of learning from the errors and modifying behaviors appropriately. The presence of a strong leadership supported by organizational commitment is essential in driving these changes. A national, provincial or territorial quality care council dedicated solely for the purpose of enhancing patient safety and medical error reduction may be formed to oversee these efforts. The bioethical and emotional components associated with medical errors also deserve attention and focus.     

Medical errors: impact on clinical laboratories and other critical areas

The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1–9.3% in clinical diagnostic laboratories has been reported in the literature. Many of these errors occur in the preanalytical and postanalytical phases of testing. It has been suggested that the errors occurring in clinical diagnostic laboratories are smaller in number than those occurring elsewhere in a hospital setting. However, given the quantum of laboratory tests used in health care, even this small rate may reflect a large number of errors. The surgical specialties, emergency rooms, and intensive care units have been previously identified as areas of risk for patient safety. Though the nature of work in these specialties and their interdependence on clinical diagnostic laboratories presents abundant opportunities for error-generating behavior, many of these errors may be preventable. Appropriate attention to system factors involved in these errors and designing intelligent system approaches may help control and eliminate many of these errors in health care.     

Managing the care of patients discharged from home health: a quiet threat to patient safety?

Threats to patient safety can originate from the overuse or underuse of care, in addition to provider-initiated errors. The past decade has seen a dramatic decrease in the duration and volume of home health services provided per patient by Medicare-certified home health agencies (HHAs). Research findings have been mixed with respect to the impact of home health utilization on patient safety and outcomes. This study aimed to explore a related yet fundamental question: How confident are home health nurses that their patients can manage their care when discharged from home health services?     

"The less-than-perfect medication system": a systems approach to improvement

The 1999 Institute of Medicine (IOM) report increased the focus by health care providers, regulators, and the public on the cause and effect of medical errors. The IOM report recognizes the complexity of the problem of medical errors and advocates a systematic approach to error reduction. Medication delivery systems in health care facilities are an excellent example of the complexity that exists. General Systems Theory (GST) provides a framework to evaluate system design and effectiveness. This article presents an example of the use of GST in the design and evaluation of medication systems with a focus on error reduction.     

Errors in medicine

Modern awareness of the problem of medical injury - complications of treatment - can be fairly dated to the publication in 1991 of the results of the Harvard Medical Practice Study, but it was not until the publication of the 2000 Institute of Medicine (IOM) report, To Err is Human that patient safety really came to medical and public attention. Medical injury is a serious problem, affecting, as multiple studies have now shown, approximately 10% of hospitalized patients, and causing hundreds of thousands of preventable deaths each year. The organizing principle is that the cause is not bad people, it is bad systems. This concept is transforming; it replaces the previous exclusive focus on individual error with a focus on defective systems. Although the major focus on patient safety has been on implementing safe practices, it has become increasingly apparent that achieving a high level of safety in our health care organizations requires much more: several streams have emerged. One of these is the recognition of the importance of engaging patients more fully in their care. Another is the need for transparency. In the current health care organizational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: 1. We need to move from looking at errors as individual failures to realizing they are caused by system failures; 2. We must move from a punitive environment to a just culture; 3. We move from secrecy to transparency; 4. Care changes from being provider (doctors) centered to being patient-centered; 5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork; 6. Accountability is universal and reciprocal, not top-down.     

Tying a Knot in the Unraveling Health Care Safety Net

The U.S. health care system continues to rely on a diverse and poorly organized health care safety net to provide care for its uninsured and underinsured residents. Last year, the Institute of Medicine (IOM) published a report entitled America's Health Care Safety Net: Intact but Endangered. The IOM cited several threats to the safety net, including inadequate monitoring of safety net function, poor integration of services, financial threats for core safety net providers, and the destabilizing effects of a rapid shift from traditional Medicaid to Medicaid managed care products. This paper reviews the findings of the IOM report, highlighting the key issues for emergency medicine. In response to the IOM's challenges, emergency departments should be used more effectively to monitor local safety net viability and to enhance the integration of community health care safety net delivery systems.     

美国医疗风险监测预警机制现状及绩效的循证评价

目的循证评价美国医疗风险监测预警机制的经验及其对我国医疗风险监管系统建立的借鉴意义。方法检索相关数据库和网络资源,全面收集有关美国医疗风险管理、医疗差错、病人安全和安全教育等方面的文献,将文献质量按循证科学的原理和方法进行分级并分类统计。结果1999年美国医学研究所(IOM)《犯错人皆难免,构建更安全的医疗卫生系统》的报告,揭示了美国医疗差错的严重性,同时指出了问题的根源并提出了解决途径。2000年,政府指定国家质量协调特别工作组(QuIC)评估IOM报告并制订了具体的整改措施。经过5年改革,在增强公众医疗差错意识、建立病人安全中心、制定医疗安全执行标准、应用信息技术、建立差错报告系统等方面取得了一定的成绩,建立了完善的医疗风险监管机制。但在风险防范方面仍存在一定不足。结论我国在建立医疗风险监管体系时应结合自身的特点:①普及和加强公众的医疗风险、病人安全意识,支持和开展病人安全相关研究;②建立医院检查审核制度和医务人员的定期考核管理制度,重视和加强医务人员的继续教育及医学生有关医疗风险知识的在校教育;③应用循证科学的原理和方法,制定涉及医疗保健系统、采购系统、药物供应系统等各个方面相应的制度和指南,规范操作制度和管理;④利用计算机信息技术,促进医院的信息化建设和规范化管理,减少人为因素的影响;⑤在选点示范、逐步推行的同时,应用循证科学的原理和方法后效评价,止于至善。     

Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety

Standardized, seamless, integrated information technology in the health-care environment used with other industry tools can markedly decrease preventable errors or adverse events and increase patient safety. According to an Institute of Medicine (IOM) report released in 1999, preventable errors have caused between 44,000 and 98,000 deaths per year. Following the report, President Bill Clinton requested that the Agency of Healthcare Research and Quality, a government agency, look into the issue and fund, at the local or state level, processes that can reduce errors. Funding subsequently was made available for research that utilizes best practice tools in clinical practice to increase patient safety.
The Joint Commission on Accreditation of Healthcare Organization has placed a great deal of emphasis on strategies to reduce patient identification errors. Fragmented systems tout the individual as well as enhanced safety applications. These applications, however, are related to prevention in specific conditions and in specific health-care settings. Systems are not integrated with common reference data and common terminology aggregated at a regional or national level to provide access to patient safety risks for timely interventions before errors and adverse events occur. Standardized integrated patient care information systems are not available either on a regional or on a national level.
This article examines tangible options to increase patient safety through improved state-of-the-art tools that can be incorporated into the health-care system to prevent errors.     

Medical errors, airplanes, and information technology

The IOM says tens of thousands die each year from medical errors. Learn lessons from the aviation industry and how we can build a culture of safety with information technology and clinical information systems.     

Errors in laboratory medicine and patient safety: the road ahead.

The Institute of Medicine (IOM) report, To err is human, galvanized a dramatically increased level of concern about adverse events and patient safety in healthcare, including errors in laboratory medicine. While a significant decrease in the error rates of clinical laboratories has been achieved and documented in recent decades, available evidence demonstrates that the pre- and post-analytical phases of the total testing process are more vulnerable to errors than the analytical phase. However, analytical quality is still a major issue, particularly in some areas of laboratory medicine such as immunoassaying. In the present paper, current trends and factors that could effect future changes in the frequency and types of errors in laboratory services are analyzed and discussed. A more effective integration of automation and information technology could allow clinical laboratories to identify, control and decrease error rates in the total testing process, but interdepartmental cooperation and communication with clinicians and other stakeholders are essential to improving patient safety. Moreover, a fundamental shift in improving patient safety in laboratory medicine is to move from error reporting to risk management.     

Second victim phenomenon: Is ‘just culture’ a reality? An integrative review

BackgroundDespite rigorous and multiple attempts to establish a culture of patient safety and a goal to decrease incidence of patient deaths in the health care, estimations of preventable mortality due to medical errors varied widely from 44,000 to 250,000 in hospital settings. This magnitude of medical errors establishes patient safety as being at the forefront of public concerns, healthcare practice and research. In addition to the potential negative impact on patients and the healthcare system, medical errors evoke intense psychological responses in health care providers' responses that threaten their personal and professional selves, and their ability to deliver high quality patient care. Studies show half of all hospital providers will suffer from second victim phenomena at least once in their careers. Health care institutions have begun a paradigm shift from blame to fairness, referred to as ‘just culture’. ‘Just culture’ better ensures that a balanced, responsible approach for both providers who err and healthcare organizations in which they practice, and shifts the focus to designing improved systems in the workplace.ObjectivesThe aim of this review was to identify: how medical errors affect health care professionals, as second victims; and how health care organizations can make ‘just culture’ a reality.DesignAn integrative review was performed using a methodical three-step search on the concept of second victims' perceptions and responses, as well as ‘just culture’ of health care institutions.ResultsA total of 42 research studies were identified involving health care professionals: 10 qualitative studies; eight mixed-method studies; and 24 quantitative studies. Second victims' perceptions of the current ‘just culture’ included: 1) fear of repercussions of reporting medical errors as a barrier; 2) supportive safety leadership is central to reducing fear of error reporting; 3) improved education on adverse event reporting, developing positive feedback when adverse events are reported, and the development of non-punitive error guidelines for health care professionals are needed; and 4) the need for development of standard operating procedures for health care facility peer-support teams.ConclusionsSecond victims' perceptions of organizational and peer support are a part of ‘just culture’. Enhanced support for second victims may improve the quality of health care, strengthen the emotional support of the health care professionals, and build relationships between health care institutions and staff. Although some programs are in place in health care institutions to support ‘just culture’ and second victims, more comprehensive programs are needed.     

Medical Errors—What and When: What Do Patients Want to Know?

OBJECTIVES: 1) To determine how and when emergency department (ED) patients and their families wish to learn of health care errors. 2) To assess the error threshold this population believes should trigger reporting to government agencies, state medical boards, and hospital patient safety committees. 3) To evaluate the role patients and families believe medical educators should play in this process. METHODS: A 12-item survey was administered to a convenience sample of ED patients and families during evaluation in a tertiary care academic ED. Results were tabulated and data were reported as percentages. Statistical significance was analyzed using the chi-square test. RESULTS: 258 surveys were returned (80%). A majority of respondents wished to be informed immediately of any medical error (76%) and to have full disclosure of the error's extent (88%). An overwhelming majority of respondents endorse reporting of errors to government agencies (92%), state medical boards (97%), and hospital committees (99%). Most respondents believe medical educators should focus on teaching students to be honest and compassionate (38%) or on how to tell patients about mistakes (25%). The frequency of hospital admission or physician visits per year had no impact on any response pattern (ns with chi(2) test). CONCLUSIONS: Regardless of health care utilization, a majority of respondents want full disclosure of medical error and wish to be informed of error immediately upon its detection. Respondents support reporting of errors to government agencies, the state medical board, and hospital committees focused on patient safety. Teaching physicians error disclosure techniques, honesty, and compassion were endorsed as a priority for educators who teach error management.     

Improving patient safety--how can information technology help?

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REPORTS by the Institute of Medicine (IOM) have brought patient safety concerns to the forefront in many health care facilities.

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THE IOM AND OTHER ORGANIZATIONS have said that increased use of technology has the potential to increase patient safety.

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THIS ARTICLE looks at the reasons behind the increase in health care errors involving patients and considers how technology could help resolve some of these problems. AORN J 80 (August 2004) 295-302.

     

患者的安全共同的责任

患者安全是护理质量中基本和重要的部分。然而，国际卫生保健系统是易于出现过失的，并且对患者的安全性护理是有害的，是基本系统缺陷所造成的。大量的利益相关者（社会大众、患者、护士、护理教育者、管理者和研究者、医师、政府和立法机关、职业协会和委任机构）对促进患者安全出院及无伤害发生是负有责任的。本文讨论了护理缺陷中相关者对患者安全的职责与特殊功能及继续接受和促进安全护理。     

Patient safety: a shared responsibility

Patient safety is an essential and vital component of quality nursing care. However, the nation's health care system is prone to errors, and can be detrimental to safe patient care, as a result of basic systems flaws. A variety of stakeholders (society in general; patients; individual nurses; nursing educators, administrators, and researchers; physicians; governments and legislative bodies; professional associations; and accrediting agencies) are responsible for ensuring that patient care is safely delivered and that no harm occurs to patients. The responsibility of these stakeholders in addressing patient safety in the context of a nursing shortage is discussed, along with specific actions they have taken, and can continue to take, to promote safe care.     

Nurse Leaders: Transforming Interprofessional Relationships to Bridge Healthcare Quality and Safety

Health care remains an exceedingly complex, high-risk industry with the potential for errors resulting in patient injury or mortality. Many health care systems have progressed toward high reliability principles to improve quality and safety. Nurse leaders are integral to high reliability as they establish a vision and operational objectives that permeate an organizational commitment to safety. Interprofessional relationships and team dynamics among clinicians can enhance or impede their ability to collaborate and provide care. In this paper, we discuss the influence of clinician relationships on health care performance and provide insights into nurse leader interventions to improve interprofessional collaboration and drive high reliability.