The Role of Nurses in Patient Safety - Essay Example

The Role of Nurses in Patient Safety Introduction Nurses have a critical role to play in ensuring the safety of their patients. Many changes are taking place in the nursing profession, and issues of accreditation increase in workload and healthcare staff and research are taking center stage. Patient safety is a critical aspect of the nursing profession and all health care in which they work. Policy makers understand the interconnectedness between this issue and healthcare outcomes. Although nurses, too, understand the need to maintain high standards of patient safety and healthcare outcomes, they are sometimes constrained by the working environments. There are many factors that determine the extent to which unnecessary and avoidable deaths are avoided in hospitals. The Role of Nurses in Patient Safety One of the factors that determine the extent to which nurses maintain safety is the working environment. In 2004, The Institute of Medicine released a report in which serious concerns were raised on the impact of the mode of hospital restructuring on the working environments of nurses and the safety outcomes of patients (Laschinger, 2006). Nursing leadership plays a pivotal role in determining the quality of work-life balance that nurses maintain. The main leadership areas that are worth assessing include policy involvement, support for an effective nursing model of medical care, staffing levels and physician/nurse relationship. Staffing levels tend to have a direct effect on use of a specified nursing model of medical care and emotional exhaustion (Laschinger, 2006). It also affects the extent to which nurses derive a sense of personal accomplishment on their work. These factors have a profound influence on patient safety outcomes, either directly or indirectly. The use of technology by nurses also presents a new dimension to the occurrence of error risks, particularly those ones relating to prescription. Although computerized physician order entry systems are conventionally considered the best technical solution to prescription errors, they are not completely error-proof (Koppel, 2005). Few researches have been done on how the emerging errors relating to use of these computerized systems can be prevented. Some of the errors emerging from use of computerized systems include fragmentation of displays, which prevent a clear, coherent understanding of patients’ medications. Sometimes, pharmacy inventory displays may be mistaken for guidelines on dosage. Additionally, antibiotic renewal notices that have been placed on paper charts instead of the computerized system may be ignored. When functions are separated, this leads to double dosing and incompatibility of orders. The resulting ordering formats end up being inflexible, thereby generating wrong orders. In a study done by Koppel, one computerized physician order entry (CPOE) system was found to be a leading facilitator of medication error risks, which many nurses reported to occur frequently. Seventy five percent of the house staff interviewed reported that these errors occurred on a weekly basis or more often. Koppel (2005) noted that opportunities for reducing these errors significantly could be created through quantification of all error risks that had not been previously considered using survey and multiple qualitative methods. In order for these computerized systems to be effective, nurses, clinicians and hospitals need to attend to both the errors that the systems cause, as well as the errors that they are aimed at preventing (Koppel, 2005). It is often suggested that system approaches such as improvement of working conditions can improve patient safety greatly. However, little is known about the impact of many variables relating to working conditions on patient outcomes Stone & Mooney-Kane, 2007). In an observational study, Stone & Mooney-Kane (2007) used the Medicare files and The National Nosocomial Infection Surveillance system in order to capture the distinct dimensions of severity of patient illness as well as risk for disease. Fixed setting and health status characteristics were used in the assessment of the role played by various working condition variables. The valuables assessed include overtime, objective staffing measures, wages information derived from payroll statistics, magnet accreditation and hospital profitability. The researchers found out that there was a strong association between nurse working conditions and all the outcomes that were measured. It was also found out that improving the nurses’ working conditions is highly likely to promote patient safety. However, further research is required in order for many other working condition variables to be assessed (Stone & Mooney-Kane, 2007). The safety culture that nurses have nurtured also plays a significant role in the level of patient safety that is recorded in different medical facilities. The nursing leadership plays a critical role in shaping perceptions on patient safety. According to Ginsburg & Norton (2005), training initiatives that are sensitively delivered for nurse leaders can greatly help in fostering a safety culture. Organizational leadership support relating to improvement issues is also critical for fostering and nurturing a culture of patient safety. The nature and extent of adverse effects recorded varies depending on the circumstances in which nurses operate (Kane, 2007). Staffing levels in of registered nurses, for instance, greatly determine the risk of adverse effects occurring. Moreover, trends on adverse effects and patient outcomes in acute care hospitals differ from those that are experienced in other types of hospitals and health care centers. Studies conducted using different designs reveal correlations between increased RN staffing and significantly lower hospital-based adverse patient events and mortality (Kane, 2007). Additionally, hospital and patient characteristics determine the extent to which nurses plays a proactive role in preventing adverse patient events from occurring while at the same time improving patient outcomes. Nurses who work in hospitals where there is minimal commitment to quality of health care may feel constrained in terms of the measures that they can take in order to improve patient outcomes. The role that nurses play in improving patients’ outcomes ought to be appreciated by policymakers since these are the healthcare professionals who are always in the closest proximity with patients most of the time. They understand the needs of critically ill patients. They are required to maintain high-intensity care for such patients. Furthermore, they are required to exercise extra caution in order to avoid making serious errors, which could lead to fatal consequences. After carrying out a prospective one-year observational study, Kane (2007) observed that adverse effects and extremely serious errors that involve critically ill patients are common and are potentially life-threatening. Although Kane identified many types of errors, the leading category comprised of those errors arising from failure by medical professionals to give the intended treatment. This study was based on the collection of incidents using a multifaceted approach, including the use of direct continuous observation. An independent assessment was made on two physicians with regard to severity, preventability, incident types, and performance failures. This research is highly relevant for policy makers with an interest in determining the dynamics of two different types of errors that take place in hospitals: individual performance and systems-related failures. Factors that may be used to prevent or reduce errors and adverse events Many factors need to be assessed in terms of their appropriateness in preventing or reducing errors and adverse events in healthcare facilities. Different stakeholders have important roles to play in ensuring that all these factors are analyzed, assessed and corrective measures are taken in order to improve patient outcomes. Researchers have recently been exploring the nature of medication errors on the basis of demographic considerations, healthcare settings, and working conditions. Fortescue (2003) notes that medication errors among pediatric inpatients tend to occur at almost similar rates as adults, although their likelihood of causing harm is three times more compared to that of adults. According to Fortescue (2003), the measures that have the greatest potential of reducing medication errors include use of computerized physician order entry systems, improvement in communication among nurses, physicians and pharmacists, and use of ward-based clinical pharmacists. These measures are particularly highly effective among pediatric inpatients. In the case of computerized systems, clinical decision support systems are needed in order for their efficacy to be greatly increased. Barach & Small (2000) puts the notion of adverse effects in sharp focus by reporting that about 100,000 patients die preventable deaths every year in US hospitals. Many more incur injuries that cost the US federal government $9 billion annually. Moreover, there is a gross underreporting of the country’s adverse events, which range between 50% and 96%. This annual figure is far much higher than the combined number of injuries and deaths that arise from suicides, motor accidents, air crashes, falls, drowning and poisonings. There are many scientific, moral, practical and legal dilemmas that surround these medical mishaps. To solve this problem, an environment that fosters an extremely rich reporting culture should be created. Such an environment should capture detailed and accurate data about all nuances of care (Fortescue, 2003). In complex medical work settings, outcomes are dependent on how individual, technical, team and organizational factors are integrated into different medical interventions. The continuum of different cascade effects that exist emanate from accidents that are apparently trivial. They may also be in the form of more serious near-misses, or even full-blown adverse events which are at the other extreme end of the continuum. For this reason, the patterns that define the causes of failure are similar in both near-misses and in adverse effects. The actual outcome is dependent on the recovery mechanisms that are adopted at the outset. Health practitioners, particularly nurses, should focus on data on near-misses rather than adverse events when they are planning on which intervention measures to adopt. They should focus on safety ‘incidents’ in order to intervene before they turn into accidents. The available schemes for reporting near-misses include should be properly utilized in order to reduce the number of people who die of preventable deaths while they are in hospital. Adverse drug events constitute another form of adverse events that have not been subjected to sufficient research attention (Nebeker, 2005). Adverse drug events can be established in almost all stages of a computerized medication process. Therefore, today’s computerized medication administration systems constitute a key factor in the proliferation of adverse events in healthcare facilities. According to Nebeker (2005), most of the errors relating to adverse drug events (ADE) (61%) occur during ordering. The ADE proportions include dispensing (1%), administration (13%), and monitoring (25%). During these events, the outcomes may range from serious harm to additional monitoring and interventions. Lack of decision support during the selection, dosing as well as monitoring of drugs is to blame for this high rate of adverse drug events. If nurses employed decision support measures after the use of CPOE systems, most adverse drug events would be avoided. Morimoto (2007) notes that ADEs, medication errors, and potential ADEs can easily be collected by extracting information from practice data, patient surveys, and solicitation of various incidents from health professionals. Practice data may include laboratory information, charts, prescription data, and reviews of administration databases. A systematic approach to detection and classification of ADEs is a good basis for measuring and improving medication safety in healthcare facilities. According to a recent report by The Institute of Medicine, the data that is increasingly being revealed indicates that there are frequent errors being made in medicine, which leads to substantial harm (Gurwitz, 2005). The magnitude of this problem is worrying, public interest is growing and the consequences of medical errors are being blamed on poor professional practices by nurses and physicians (Gurwitz, 2005). Clinical decision support needs to start being used judiciously in order for adverse effects to be avoided. Consequent actions ought to be adopted when medical systems are being designed. Existing systems ought to be tested in order to ascertain whether they can catch errors that have a huge potential of injuring patients. It is unclear whether any standards exist on adoption of different systems. Moreover, the issue of incompatibility between different systems could be a key source of medical errors, for instance, paper-based ordering systems versus computerized ordering systems (Gurwitz, 2005). Various stakeholders in the healthcare sector feel that use of provider order entry systems particularly computerized prescribing can be improved through implementation of bar-coding for medications (Koppel, 2008). Similarly, the same form of reinforcement can be used in the utilization of modern electronic systems in order for key asynchronous data to be communicated efficiently. Better linkages among systems can be improved in order for the entire process to be greatly simplified without compromising on outcomes (Gurwitz, 2005). Nursing managers have been looking for the best ways of improving the safety of health care centers where their personnel work. At the same time, they have to address issues relating to nurse recruitment, retention and appraisal. The quality of nurses’ work environment touches on both these two concerns. Many researchers have tried to establish a theoretical link between the quality of nursing practice and a culture that guarantees employee safety (Hall, 2005). Power and control are essential factors for nursing managers to consider. These managers ought to increase nurses’ access to opportunities relating to empowerment structures. This may lead to an increase in a culture of patient safety. Today, policymakers have access to tones of information on the occurrence of adverse effects within the healthcare system. This information is a good basis for corrective measures to be adopted by various stakeholders. Over the last decade, several reports have been released which indicate that between 5% and 15% of all patients who are admitted in hospitals encounter an adverse effect (Rothschild, 2005). Moreover, the reports indicate that quite a significant proportion of these adverse effects (37%-52%) can be prevented. When focus is put only on the examination of how incidences of adverse effects occur and the consequences, this leads to shifting of emphasis away from weaknesses in organizational and systemic conditions that case the adverse effects in the first place (Tourangeau, 2006). All stakeholders are needed for the work of examining these systems as well as the design of an effective healthcare system that is founded on patient safety. In this regard, a good starting point would be to understand all the factors that cause adverse effects, and the resulting policy and practice implications. Focus ought to be put on determining all the multiple causes of adverse effects, with emphasis being put on organizational determinants (Clancy, 2009). A critical analysis of adverse effects shows that mortality rates that are adjusted on the basis of both risks and cases are the best basis for determining the level of patient safety. Mortality rates remain crucial indicator of patient safety levels mainly because some hospitals have processes and structures that can minimize unnecessary or avoidable patient deaths better than others. Additionally, there is always a need for effective risk adjustment to be made on case mix within hospitals as well as patients’ own characteristics. Conclusion Nurses have a critical role to play in ensuring that adverse effects are prevented or reduced. Policymakers in the healthcare system should put the right measures in place in order to ensure that the working environments of nurses enables them to take care of their patients in the best possible manner. Today, computerized physician order entry systems are being integrated into the healthcare systems. These systems have been efficient in streamlining the activities of healthcare providers. However, there is need for new challenges relating to adverse effects and employees with regard to these new systems to be addressed. For instance, clinical decision support systems need to be put into place in order to maintain the compatibility within and among different systems. Further research needs to be done on the continuum of medication errors and the role that nurses and physicians should play in mitigating negative outcomes. Such a continuum can be observed in adverse drug effects, whereby adverse events are normally categorized into near-misses, serous near-misses and full-blown adverse effects. References Barach, P & Small, S 2000, Clinical Review: Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems, BMJ, no. 320, p.759. Clancy, C 2009, Nurses' Role in Patient Safety, Journal of Nursing Care Quality, 24(1), 1– 4. Fortescue, E 2003, Prioritizing Strategies for Preventing Medication Errors and Adverse Drug Events in Pediatric Inpatients, Pediatrics, 111(4), 722-729. Ginsburg, L & Norton, P 2005, An Educational Intervention to Enhance Nurse Leaders' Gurwitz, J 2005, Incidence and preventability of adverse drug effects in nursing homes, The American Journal of Medicine, 109(5), 87-94. 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