To Do No Harm the Focus of Safety
Angela Zielinski
Baker School of Nursing
To Do No Harm the Focus of Safety
In 1852 Florence Nightingale wrote “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”. The goal of any medical facility should be that no preventable harm should befall the patient. Though this may seem to be an obvious goal, this very goal took second place to medical and scientific advances. In 2000, the article To Err is Human: Building a Safer Health System published by the Institute of Medicine, drew attention back to what had once been a foundational goal of patient safety when in the care of the health system. Today, preventable medical
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The article stresses that in order to maintain a culture of safety, nurses and caregivers must be encouraged to report medical errors, near misses or adverse events without fear of retaliation. The agreement of a need of culture of safety in which nurses can be accountable without punishment is further addressed in an article by Battie, Steelman (2014) entitled Accountability in Nursing Practice: Why it is Important for Patient Safety, stresses that it is important that when a nurse is aware of a breach in patient safety that she needs to draw attention to the breach regardless of who or what caused it in order to prevent patient harm. This draws attention to a need for open communication and for understand that accountability need not be a venue for …show more content…
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By keeping the lines of communication open between leaders and staff, healthcare organizations can encourage and empower nurses to solve blame game issues without fear of punishment by management. Leaders and nurses must work as a team and are capable of providing safe and quality environment. When an error or incident happens, many leaders investigate everything and everyone except themselves. In the process of patient care, harm might occur; the culture often prefers to blow the blame game whistle instead of learning from the mistake. Nursing in fear, often refrain to openly admit mistakes and errors, which hinder the objective to ensure everyone is cared with compassion and dignity.
Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency
The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a
Medicine is an always evolving field, and continues to grow in the pursuit of people health benefit. As time has passed better research studies, discoveries, treatments and improvement of patient outcomes has been the pride of the medical field. However; despite all the improvements in medical advancement, preventable medical errors have become a major problem in the field. About a decade ago, the Institute of Medicine (IOM) investigated and created the report To Err Is Human: Building a Safer Health System, in that report the IOM came to the conclusion that approximately 98,000 people has died yearly in the United States as a consequence of an preventable medical error (RWJF, 2011). Some of these errors are caused
In a perfect world, these defenses would be impenetrable and patients would always be safe.20-22 But that isn’t the case. These defenses, like slices of Swiss cheese, have holes—latent and active failures—that do not always prevent the human error from reaching the patient. Each piece of cheese (barrier) has holes, and when these holes line up, an error occurs. When defenses fail in health care, a patient or staff member is endangered or harmed. While leaders can and should support defenses and interventions to reduce risk, this is not enough; a culture of safety must also be established.30 In order to make progress in reducing harm and barriers to incident reporting, for further improving quality in healthcare, the most essential change needed is cultural, and in particular from a blame culture to a safety
In 2012 World Health Organization reported an estimate of one in ten people being subject to harm whilst hospitalized in developed countries. Patient safety is the epitome of healthcare as this is indicated by the ongoing systematic reviews by health organizations worldwide. Nurses duty of care to patients is ensuring and maintaining patient safety during their admission in hospital (Ammouri, et al 2012). Failure of effective handoff/handover communication between healthcare providers has been found to be the cause of approximately 80% of serious medical errors (Huang et al, 2010). This article will focus on communication between caregivers, lack of leadership and teamwork, lack of reporting systems, inadequate analysis of adverse events and inadequate staff knowledge about
Healthcare is a business and a large one at that. Hospital spending alone is expected to reach one trillion dollars when final numbers are released for 2015 (Centers for Medicare and Medicaid, 2016). With this type of spending, hospitals are uniquely charged with improving the health of the residents in their communities. At no time, should the health care provider cause harm. However, harm is what has occurred in health care. Due to a fragmented health care system, health care is in turmoil (Kohn, Corrigan, & Donaldson, 1999). It was estimated in the 1999 book, To Err is Human that anywhere from 44,000 to 98,000 people die each year in hospitals due to medical errors (Kohn, Corrigan, & Donaldson, 1999). Initiatives were put into place to combat
As we all know, patient safety in a healthcare setting is extremely important and is to be taken very seriously. This is a very challenging topic with any healthcare establishment, because people do make errors and it’s only human. It is everybody’s job within the facility, hospital, or any healthcare setting to work on making sure that the safety of every patient that enters and leaves their building is safe. We want patients to feel safe and confident when they have to go to the hospital for a procedure, or even to a skilled nursing facility to have rehabilitation or to eventually stay long term.
I agree with you, “Medical error prevention” is a priority for the future of the healthcare in the United States. “Preventable medical errors in hospitals are the third leading cause of death in the United States”. “Medical harm is a major cause of suffering, disability, and death – as well as a huge financial cost to our nation”. (Sanders, B., 2014).
Each year between 210,000 and 440,000 patients go to the hospital for care suffers some type of preventable harm that contributes to their death (Allen). Knowing that so many patients go into a hospital and never leave due to mistakes made by a physician or nurse is extremely sickening. Physician and nurses have to sometimes slow down and double or even triple check information that have entered into patients chart or doses they are about to administer to an patient. I know it is hard sometimes to slow down because there are so many patients that needed to be attended to at any given moment. Hospitals now are becoming very crowded and sometimes the patients are in pain as well as inpatient. Nurses and physician are trying to do their best to ensure that they touch bases with
The report makes it publicly known the harsh implications that errors in healthcare are a leading cause of death and injury. In the late1999, Institute of Medicine (IOM) of the National Academies of the United States released the report, To Err Is Human: Building a Safer Health System. The report cited the findings of a major study that found medical errors kill at least 44,000 and perhaps as many as 98,000 Americans in hospitals each year. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (l6, 5l6). Total national costs are estimated to be between $37.6 billion and $50 billion for these events. A depressing comparison of about 6,000 Americans die from workplace injuries every year and medication errors are estimated to account for about 7,000 of this deaths (Gray, E., Gray, I., Yodice P., Rezai, F., Fless, K.).
Safety in care not only impacts patients and families who utilise health care services, but also impacts the organisation as a whole (Landgren, 2008). Overwhelming evidence has found that failure to meet quality standards of care may result in negative outcomes, such as increased costs for organisations, permanent injury, increased length of stay for patients and even death (Steinwachs & Hughes, 2008). Furthermore, failure to meet standards of care puts the organisation’s reputation in jeopardy, as this reflects the standard of care that people would expect from such health institutions (Steinwachs & Hughes,
Patient safety is a critical part of quality care, and there is no question that how significant patient safety is. Every day we face several complex matters regarding patient care that forces us to think and act carefully. “Stories of patients having the wrong surgery performed, the wrong medication being administered, or dying from hospital acquired infections are too often the lead story on news programs” (Gomez, 2014). However, to bring down the percentage of safety risk, requires an organization that understanding and supporting a culture of safety in the workplace. Communication between the team is very crucial, also focusing on providing feedback on potential areas of concern help patient safety.
“Nursing is an art, and if it is to be made an art, requires as exclusive a devotion, as hard a preparation, as any painter’s or sculptor’s work...” (Nightingale, 1868)
Patient safety which is the amount to which patients are free from unintentional injury has established a great deal of media attention during the past few years. Regulatory and professional agencies have specified that patient safety education should be given to healthcare workers to improve health results. The primary purpose of this essay was to gain a better understanding of the present status of patient safety consciousness among those that work in the health care setting... Risk Management Issue