OM 001 Patient Safety And Quality Of Services
OM 001 Patient Safety And Quality Of Services
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 Harteloh3 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 dissatisfaction5—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.
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).
