The Effects of œTo Err is Human i nNursing Practice

Order Description Write thoughts on how the development of information technology has helped address the concerns about patient safety raised in the œTo Err is Human report. Summarize how informatics has assisted in improving health care safety in your organization and areas where growth is still needed. Legal Issues œI ‘ve made a mistake. This simple statement, or its mere thought, is enough to strike fear within the most experienced and knowledgeable of health care pro – fessionals. No matter how many times a procedure has been done or a medication administered, there is always the likelihood of prevent – able error. Each year, the public is reminded of the potential for mistakes as the media report medical horror stories where, for example, unknowing patients have surgery performed on the wrong body part, a wrong medication administered, or a foreign object errantly left inside their bodies. These reports highlight the biggest fear of health care workers”their own fallibility. Through carelessness, assumption, overt act, or omission, the health care professional can easily err and cause harm to the patient. In addition to the pain caused to the patient, health care providers also understand the devastating impact that such errors can wreak on their own personal and professional lives. The purpose of this article is to About the Authors Mr. Plawecki is Registered Nurse, Rehabilitation Hospital of Indiana, In – dianapolis, and Dr. Amrhein is Resident Physician, Family Practice Medicine, Ball Memorial Hospital, Muncie, Indiana. The authors disclose that they have no significant financial interests in any prod – uct or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Lawrence H. Plawecki, RN, JD, LLM, Regis – tered Nurse, Rehabilitation Hospital of Indiana, 4141 Shore Drive, Indianapolis, IN 46254; e-mail: Lawrence.plawecki@ doi:10.3928/00989134-20091016-01 Clearing the Err Reporting Serious Adverse Events and œNever Events in Today’s Health Care System Lawrence H. Plawecki, RN, JD, LLM; and David W. Amrhein, MD Abstr A ct Absent an infinitesimal percentage, most Americans seek health care ser – vices due to a legitimate health issue. Fundamental within this relationship is the understanding that health care professionals will do everything within their power and expertise to alleviate the suffering of each patient they treat. Unfortunately, preventable medical errors do occur, and the in – nocent patient is left to suffer. In 1999, the Institute of Medicine released t o e rr Is h uman: b uilding A s afer h ealth s ystem , the first mainstream publication calling for a change in the culture of health care and the eradication of prevent – able medical errors. In the 10 years since its publica – tion, federal and state governments and agencies have been proactive in attempting to meet the recommendations originally proposed in t o e rr Is h uman . This article will review what has been ac – complished in this time frame. © Ireneusz Skorupa 26 discuss the trend in today’s health care systems toward the reporting of serious adverse events or œnever events, as well as the impact”both impending and current”on the role of geriatric nurses. r efocus I ng A nd r ebu IL d I ng A sA fe He AL t H cA re s ystem In November 1999, the Insti – tute of Medicine (IOM) released a profound call to action for everyone involved in the health care commu – nity. This statement, entitled To Err Is Human: Building A Safer Health System , began with a grim statistic, estimating that between 44,000 and 98,000 people died per year from preventable medical errors as hospi – tal patients. The IOM (1999) report defined medical error as the use of a wrong plan of action to achieve an aim or the planned action’s failure to be completed as intended. In economic terms, these errors were estimated to cost between $17 billion and $29 billion per year across the country (IOM, 1999). These financial estimates include the costs of lost income, lost household productivity, and the cost of the additional health care necessitated by the errors (IOM, 1999). The more specific recommen – dations posited by the IOM (1999) for the prevention of medical errors are discussed below. The IOM (1999) report recom – mended a four-tiered approach to achieve a better safety record: l Establishing a national focus to create leadership, research, tools, and protocols to enhance the knowledge base about safety. l Identifying and learning from errors by developing a nationwide public mandatory reporting system and by encouraging health care organizations and practitioners to develop and participate in voluntary reporting systems. l Raising performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups, and purchasers of health care. l Implementing safety systems in health care organizations to ensure safe practices at the delivery level. As a result of these broad rec – ommendations, state and federal governments, agencies, and health care institutions were given notice about the increased focus on the prevention of medical errors and, consequently, the improved safety of the patient receiving treatment. During the 5 years following the IOM (1999) report, progress began to be made. In 2001, the U.S. Congress ap – propriated an annual budget of $50 million for patient safety research (Leape & Berwick, 2005). From this appropriation, the Agency for Healthcare Research and Quality (AHRQ) was codified as the federal agency to oversee patient safety and its improvement (Leape & Berwick, 2005). AHRQ became an important player in the new patient safety movement by evaluating health care practices to determine effectiveness, educating health care institutions about how to best report errors and adverse events, and creating a road – map of evidence-based best practices (Leape & Berwick, 2005). Using the roadmap created by AHRQ, the National Qual – ity Forum (NQF) (2007) created a list of 27 serious reportable events, also referred to as never events , which were offered as the basis for a potential national reporting system chronicling patient safety. The serious reportable events may be divided into six separate cat – egories, including surgical events, product or device events, patient protection events, care management events, environmental events, and criminal events (NQF, 2007). For the purposes of this article, however, the individual events will not be dis – cussed, as the focus is to remain on the implementation and evolution of patient safety standards. In 2005, the American Medi – cal Association (AMA) released a report by Leape and Berwick detailing the effects of the origi – nal IOM publication. The AMA report, while admitting there had been little measurable effect after the release of the IOM report and that no comprehensive nationwide system for monitoring had been put into existence, discussed how the focus of patient care had shifted from fixing blame to implementing a culture of safety (Leape & Berwick, 2005). This alone can be considered an impressive feat in today’s increas – ingly litigious society. Furthermore, Leape and Berwick (2005) identified the four areas the health care system needed to advance in the following 5 years to facilitate the transition to a patient safety focus. First, Leape and Berwick (2005) recommended the implementation of electronic medical records. It is argued that this implementation, al – though a substantial initial cost, will save the facility and pay for itself due to the decrease in charges of ad – verse events and increase in efficien

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