Systems Issues and Human Factors

Preventing errors and other causes of harm or injury to patients often depends on the environment in which the patient care is being delivered and also depends on the interaction between healthcare providers themselves, with the system in which care is provided, and with the patient and family. The focus for the cause of patient injury can be an individual (such as a fatigued nurse who forgets to raise the bedrail for a confused patient who then falls out of bed and fractures a femur) or it can lie with the system (such as the nurse giving a patient the wrong dose of a medication – a medication that was ordered incorrectly by the provider and filled by a pharmacist who failed to note the incorrect order). In either case, there could have been appropriate actions to prevent injury to the patient. Adequate rest and staffing may have helped the fatigued nurse to be more alert or perhaps a colleague may have noticed that the bedrail was not up and raised it – thus preventing the fractured femur. If the provider, the pharmacist, or the nurse had noticed that the medication dose was not the correct one for the patient – any one of those individuals could have prevented an error from happening.

The quality of healthcare has been viewed as the umbrella under which patient safety resides. The concept of quality is abstract. Because errors are often the result of multiple causes and the interaction between those causes, they are difficult to measure. However, there are ways to measure the quality of healthcare and directly or indirectly, changes that impact patient safety. The Institute for Healthcare Improvement (IHI) summarized those as:

1. Outcome Measures – those which tell you whether changes really lead to improvement. Examples include number of Cases of Adverse Drug events per a certain number of drug doses.
2. Process Measure – changes in processes that improve the organizational culture as it relates to patient safety. An example would be the Percent of Surgical Cases with On-Time Prophylactic Antibiotic Administration.
3. Balancing Measures – Measures to make sure changes to improve one part of the system don’t cause new problems in other parts of the system. An example might be asking patients to write down a complete list of medications (including those over-the-counter) in order to prevent a potential adverse drug event - which would cause the patient to be less satisfied with their care.

It is important to measure variables that impact patient safety the same way across the country in order to benchmark practice and outcomes and measure improvement. Recently the Department of Health and Human Services contracted with the National Quality Forum to help establish a portfolio of quality and efficiency measures for use in reporting on and improving healthcare quality. These measures will allow the federal government to see more clearly how and whether healthcare spending is achieving the best results for patients and taxpayers . Part of this contract is to improve the quality of care for 20 “High Impact Conditions”. Because there are 20 medical conditions that account for more than 95% of Medicare's costs, NQF will synthesize evidence related to these 20 high-impact conditions and prioritize them to guide future development of performance measures.

Nurses play a unique role in the development of a culture of patient safety. They also face significant challenges in developing this culture. Patients have shorter stays in hospitals, the U.S. population is aging, and the nurses are aging as well… their performance is “… intimately tied to the healthcare systems within which they work.”