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E D I T O R I A L

Solutions at your fingeflips

nstitute of Medicine (IOM) committee members reported I in testimony before the 106th

Congress that medical mistakes rank eighth among the leading causes of death in the United States.’ A report released in November 1999 discloses alarm- ing statistics that medical errors are killing between 44,OOO and 98,000 people in US hospitals each year.’ The statistics do not include errors that may occur in settings other than hospitals (eg, physician’s offices, extended care facilities). Medical errors are believed to be the nation’s lead- ing cause of death and injury.’

All medical errors do not result in death, permanent disability, or suffering, however. Media reports result in more questions than answers for our patients because information is presented as though adverse events are common. Institute of Medicine committee members reported that they believe 95% to 98% of the errors are “sys- tem errors,’’ meaning they are related to equipment, procedures, or job designs. It is believed that more than 7,000 patients die each year from medication errors that occur within and outside of the hospital? One expert clarified responsibilities of those involved in patient care by stating “It’s the little mistakes that cause the big problems in patient safety.”’

HISTORICAL IMPROVEMENTS

and commitment were recog- nized as being essential for

Understanding, determination,

improvements when quality ini- tiatives in health care became a high priority. In 1986, a project titled “Agenda for Change,” which was initiated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), resembled initiatives used for quality improvement in industry. The focus of the project was to recognize clinical and organizational functions that are most important to quality care. The JCAHO believed that quali- ty patient care depended on a clear understanding of clinical, managerial, and governance functions; a determination to consistently assess the effective- ness with which these functions are being fulfilled; and a com- mitment to continually improve this effectiveness, regardless of its current level.6

word was “right”-the right activities, the right way, for the right reasons, with the right out- comes. Quality assurance efforts for preventing and minimizing errors evolved with various titles and models (eg, continuous qual- ity improvement, process improvement). Quality initiatives might be effective, but errors continue to surface. Approaches suggested by IOM committee members and President Clinton require a concerted effort by health care personnel to report and track errors. In addition, sig- nificant monetary support will be required to improve patient safe- ty using these methods.

During the nineties, the buzz-

BACK TO BASICS

The oppor- tunity for error occurs when basic practices (eg, managing traffic patterns, BRENDA s.

GREGORY DAWES cleaning, wear- ing correct attire) are not incorpo- rated into daily activities by each and every team member. Basic practices should require minimal discussion, decision making, or dissension unless they are deemed sacred cows through a rigid review process. Simply omitting practices is not acceptable, as this could result in errors that are diffi- cult to track and manage and could contribute to potentially adverse outcomes.

for perioperative nurses who prac- tice safe patient care. Basic prac- tices are rarely gray; rather, they are forced to be black and white because of regulations, recommen- dations, and guidelines. Errors can- not be justified by personal choice. When individuals decide to not follow policy and procedure or use available resources or guidelines to establish practices, or they simply are not wise enough to promote a safe arena, no explanation is satis- factory if the result is harm to a patient. Anecdotal reports of incor- rect antibiotic administration; first assisting by people who are not certified; breaks in aseptic tech- nique; preoperative shaving with razors; omitting sponge, needle,

Emphasis on errors is unsettling

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and sharp counts; or taking food and drink into an OR frequently are shared by frustrated periopera- tive nurses. Nurses who are com- fortable practicing according to regulations and using the guide- lines that are established would prefer to concentrate on patient care priorities rather than to police others who simply cannot be both- ered. Perioperative nurses who choose to battle these issues realize that the outcomes cannot and will not change without the support and commitment of all team members.

Practicing safe patient care does not require adjusting priorities. Safety and infection control meas- ures have been significant actions in perioperative settings since before quality issues surfaced. Major changes to incorporate basic practices will be necessary only if providing the highest level of patient care is not a priority.

MANDATES DICTATE RESPONSIBILITIES

tions provides opportunities. A culture of safety cannot be man- dated. We will have the benefit of overcoming patients’ questions, anger, and frustrations only if we search for resources and solutions. Perioperative nurses need to real- ize that the actions believed to be important are part of the solutions.

A mandate to commit to solu-

SOLUTIONS AT OUR FINGERTIPS This challenge is not new.

Perioperative nursing’s roles and responsibilities in protecting

patients has evolved over the years, as resources have developed to provide guidance, requirements, or regulations for safe practices. More information and research is available than ever before. Depending on the culture of the setting, the implementation of resources into practices varies. Perioperative nurses know what is not working and where the prob- lems lie. They can offer substan- tial solutions for correcting the problems that might be recognized as errors. Finally, perioperative nurses are in situations in which they can view the needs of patients, settings, and customers.

For those who believed all along that changes should occur, or for those who now are convinced that changes will make a differ- ence, the time is now. Reporting errors is not an option-the moral and ethical responsibility has been dictated. The public nature of these statistics does not allow for igno- rance of the fact that patients will challenge decisions and question information. If we look through the eyes of the individuals who need care-our patients-we can guess that they hope for support within a system that is intended to do no harm.

Perioperative nurses need to reach out to their administrators, physician partners, and other peers to communicate the basic practices that are or should be in place to protect our patients’ safe- ty. Every member of the perioper- ative nursing staff should seek

opportunities to communicate the practices that enhance safety, no matter how basic the practice seems to us. It is time to identify agenda items for physician or administrator meetings and pres- ent information in a variety of ways. Use infection control and safety meetings to discuss current practices. Meet with nurses who are working on other patient care units to help them understand assessment and evaluation criteria. Commit to knowing the resources that are available and sharing that information with every peer in the perioperative setting.

Every patient should be com- fortable that his or her care is con- sistent with best practices and assured that each team member is an active participant in providing the best care. Perioperative nurses need to realize they are at a point at which decisions to prevent errors are occurring at a federal level. The initiatives are not intended to blame but to prevent. We can lead those initiatives to a point at which it will make a difference for our patients. Perioperative nurses have the understanding, determination, and commitment to promote safe environments and prevent errors. This is one time when efforts to correct an adverse situation are at our fmgertips-all we need to do is reach out and use our resources and knowledge for our patients’ benefit.

BRENDA S. GREGORY DAWES RN, MSN, CNOR

EDITOR

NOTES

Congress. Testimony of M Wakefield, C Cassell, D Benvick. Available from http://www4.nationalacademies .org/ocga/testimon.nsf. Accessed 17 March 2000.

Safer Health System (Washington, DC: National Academy Press, 1999).

errors requires dramatic, system-wide changes.” Available from http://www4.nationalacademies.org/news. Accessed 17 March 2000.

1. The National Academies Testimony Before

2. Institute of Medicine, To Err is Human: Building a

3. “Preventing death and injury from medical

4. The National Academies Testimony Before Congress. Testimony of M Wakefield. Available from http://www4.nationalacademies.org/ocga/testimon.nsf, Accessed 17 March 2000.

5. Agency for Healthcare Research and Quality, “Chief calls for new approaches to medical errors.” Available from http://nurses.medscape.com/ reuters/prof. Accessed 19 March 2000.

6. N Graham, Quality Assessment in Hospital Strategies for Assessment and Implementation (Gaithersburg, Md: Aspen Publications, Inc, 1990) 46.

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