I find it puzzling that safety continues to be a priority concern when it comes to healthcare delivery. As a nurse, safety seems to me to be a no-brainer. Safety is at the forefront of every patient-related decision nurses make; patient education nurses provide; and the critical thinking, communication, and intervention that undergirds nursing care. But when looking at the statistics related to patient safety, there is no denying the healthcare team continues to struggle with protecting patients' safety.
Johns Hopkins researchers (Makary & Daniel, 2016) recently estimated that there are over 250,000 deaths annually in the United States related to medical errors, ranking as the third leading cause of death behind heart disease and cancer (https://www.psnetwork.org/obstacles-to-patient-safety-2). Important to recognize, Makary and Daniel (2016) are only making estimates (i.e., best guesses) related to the rate of medical error, but, considering that medical error is due to human or system error, this is a difficult statistic to contemplate.
Of note, Makary and Daniel (2016) emphasize that medical errors are not required to be directly reported, resulting in "no systematic measurement of the problem" (p. i2139). Instead, the true number of medical errors is shrouded behind confidential doors. Makary and Daniel report that according to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary indicator of health status. Unfortunately, the ICD-10 coding system does not capture most types of medical error. They note "at best, there are only a few codes where the role of error can be inferred, such as the code for anticoagulation causing adverse effects and the code for overdose events" (i2139). The authors stress that when a medical error results in death, both the physiological cause of the death and the related problem with delivery of care should be captured to more accurately identify the true incidence of medical error-related deaths.
Hospitals and care providers frequently identify and debrief after medical errors occur, but the incidence of these occurrences (including their seriousness and impact on patient outcomes) remain secreted behind closed doors. Fear of legal implications as well as impact on public perception are most likely the biggest constraints behind lack of transparency. My previous experience as a nurse researcher has been that research done in practice settings to address safety issues, even when there are positive improvements in outcomes after evidence-based interventions are put into place, are often squelched for dissemination by administrative or legal advisors who want no hint of untoward experiences shared publically. As a result, interventions that could prevent or reduce medical error are not openly shared and implemented in other settings. Further, the context behind medical errors is not disclosed which prohibits other healthcare providers' learning from these unfortunate occurrences in order to mitigate further harm. So much for transparency in healthcare.
Of course, medical error is often not due solely to human error. System error can frequently be at fault. Taking issue with Makary and Daniel's (2016) report, Shojania and Dixon-Woods (2017) point out limitations behind the Makary and Daniel article including that the authors actually reported adverse events instead of true medical error deaths. They go on to argue that "most deaths do not involve medical error and most medical errors do not produce death-but they can still produce substantial morbidity, costs, distress and enduring suffering" (p. 426). Shojania and Dixon-Woods note that preventable errors such as medication safety and pressure ulcer occurrence result in adverse events and should be just as much a concern related to patient safety. In other words, death should not be the sole outcome of interest.
Carayon and Wood (2010) agree that system error frequently contributes to issues involving patient safety and identified the need for redesign of systems and processes to address factors that contribute to patient safety. Examples of factors contributing to issues in patient safety that they identify include planning and execution mishaps (e.g., medication administration), poor communication between the healthcare team, impaired access to information (e.g., availability of patient information and order transcription), the volume of activities and tasks expected of individual members of the healthcare team, challenges in providing timely appropriate care, transition of care (i.e. delay in treatment), and the overall complexity of the healthcare system and processes.
Makary and Daniel (2016) identified three strategies to reduce deaths occurring from medical care. I believe they apply to adverse events in general: (1) make errors more visible when they occur so their effects can be minimized and prevented, (2) have interventions readily identified and available to rescue patients, and (3) minimize the occurrence of errors by following principles that take human limitations (i.e. fatigue, inattention, mental overload) into account. Additionally, Merandi & Bartman (2018) suggest that improving safety in the healthcare environment involves not only studying things that have gone wrong to improve care in the future, but anticipating errors before they ever happen. While acknowledging the complexity and variability that inherently exists in the healthcare setting Merandi and Bartman suggest there is value in focusing on how errors are avoided, which happens far more often than when things go wrong.
A vigilant focus on safety is mandatory for every nurse. Whether considering deaths due to medical errors, adverse events, or even outcomes of unfinished nursing care, any situation that has the potential to cause patient harm is a safety issue. As members of the healthcare team, nurses should take the lead in pushing innovative approaches to safety that are not only reactive but proactive for averting negative patient outcomes. We do this without thinking in our own individual approaches to care. Let's follow Merandi and Bartman's (2018) recommendation to more deliberately and outwardly demonstrate a proactive approach to patient safety. Whether reactive or proactive, let's be engaged in promoting patient safety in the gastroenterology setting.
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