Quality Of Care: Patient Safety

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Definition

According to the World Health Organization (WHO), one in ten patients is usually harmed during the healthcare process. This results in millions of incidences of patient safety annually as well as billions of US dollars in cost per year. Patient safety is an integral quality of care issue for everyone in healthcare as it promotes safer and better healthcare. The WHO further defines patient safety as the prevention of errors to the patients, which are related to healthcare (WHO, 2017). The simplicity of this definition is not meant to belittle the issue of patient safety, given that it is a discipline in healthcare with a growing body of knowledge. Healthcare errors can be as a result of several factors such as human factors, system failures, or even complexity. Examples of human factors include long working hours of nurses that cause fatigue and even depression, the failure to acknowledge medical errors due to fear of censure, and pressure due to timeframes (Hall, Johnson, Watt, Tsipa & O’Connor, 2016). System failures are as a result of poor hospital organizational structure. A good example of a system failure is an unclear chain of command between physicians and nurses, hence resulting in poor communication between different practitioners. This can result in errors which can jeopardize the patient safety.

 

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History

Patient safety was not a widely considered issue before the year 1999 when a report titled “To Err is Human: Building a Safer Health System” by the Institute of Medicine (IOM) was released. After that, the media heavily publicized the issue leading to a closer look into patient safety by all stakeholders, to find how to solve the issue. The report by IOM recommended ways to improve patient safety including reporting mechanisms while discouraging blame games in hospitals (Donaldson, 2008). Ever since this report, a lot of studies have been done which resulted in the establishment of Safety I. This standard is, however, being replaced by Safety II to improve on its shortcomings.

How it is measured and monitored

The Agency for Healthcare Research and Quality (AHRQ) under the US DHHS proposes several measurements and monitoring methods of patient safety including Voluntary error reporting systems, retrospective chart review, automated surveillance, patient reports, and claims data. Furthermore, the Medicare Patient Safety Monitoring System (MPSMS) measures and monitors the safety of healthcare delivery systems aimed to reduce error (Hunt et al., 2005).

References

Donaldson, M. S. (2008). An overview of to err is human: re-emphasizing the message of patient safety. Agency for Healthcare Research and Quality (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2672/?report=reader

Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016). Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One, 11(7), e0159015.

Hunt, D. R., Verzier, N., Abend, S. L., Lyder, C., Jaser, L. J., Safer, N., & Davern, P. (2005). Fundamentals of Medicare patient safety surveillance: intent, relevance, and transparency. Agency for Healthcare Research and Quality (US), Rockville (MD). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK20489/#!po=92.5000

WHO, (2017). Patient safety. World Health Organization. Retrieved from: http://www.who.int/patientsafety/en/

 

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