The Institute of Medicine's (IOM) 1999 landmark report, To Err is Human: Building a Safer Health System, acknowledged that about 98,000 lives are lost each year from medical error in hospitals in the United States. The IOM defines medical errors as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim."1
Common errors that occur during the provision of healthcare include: adverse drug events, improper transfusions, surgical injuries, wrong-site surgeries, suicides, infections, restraint-related injuries, falls, burns, pressure ulcers, and mistaken patient identities.1
Beyond the cost of human lives, the estimated cost of medical errors is between $17 billion and $29 billion per year in hospitals nationwide.1
Fifteen years later, what does your organization's safety culture look like? If your organization is like most, you still have work to do, in fact, the journey never really ends. A commitment to safety requires the collaboration of all levels of staff, from frontline care providers to managers and executives. The cooperation of everyone establishes a culture of safety, which creates a blame-free, trusting environment where staff can report errors and near misses without fear of retaliation. A culture of safety encourages collaboration at all levels to identify solutions for safety issues. A culture of safety exists when all staff is held accountable for the safe outcomes of patients. A culture of safety can positively impact length of stay, medication errors, ventilator-associated pneumonia, bloodstream infections, pressure ulcers, and staff morale.
Sometimes the steps required to decrease medical errors seem very simple. For example, if you perform hand hygiene, you'll decrease the spread of infection. But you have to create an environment where people (including patients) feel empowered to speak up in a respectable way to remind you to wash your hands.
The Agency for Healthcare Research and Quality has a Hospital Survey on Patient Safety Culture. It's a staff survey designed to help hospitals assess the culture of safety in their institutions.2 Do you know if your hospital utilizes this survey? If so, have you completed it? Do you know the results?
We all are responsible for patient safety. Think about what you can do to impact your organization's culture of safety. Johns Hopkins Center for Innovation in Quality Patient Care offers resources to create a culture of safety, adopt a Comprehensive Unit-based Safety Program, improve ICU and perioperative safety, and increase hand hygiene.3 Check it out. Also take the time to read Joanne Farley Serembus' article on Improving the Critical Care Safety Culture in this issue.
Until the next time, be healthy, be happy, be great advocates for your patients, and get out there and create a culture of safety!
AnneMarie Palatnik, MSN, APN, ACNS-BC
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