Patient safety is defined as the prevention of harm to patients, where harm can occur through errors of commission and omission (Institute of Medicine [IOM], 2003). Florence Nightingale laid a solid foundation in the improvement of patient safety. In Notes on Nursing, she wrote, "Every nurse ought to be careful to wash her hands very frequently" (p. 53). Miss Nightingale also used statistical analysis to examine why soldiers died during the Crimean War.
Moving forward 150 years, in 1999, a widely publicized report, To Err Is Human: Building a Safer Health System (IOM), helped to launch a concerted national effort to improve patient safety in all care settings. This seminal report called for a comprehensive approach that includes mandatory and voluntary reporting systems and a national center for patient safety (housed in the Agency for Healthcare Research & Quality [AHRQ]). Healthcare organizations were also challenged to create a culture of safety, with systems designed to prevent, detect, and minimize error while not attaching blame to individuals.
Since 1999, policy makers, regulators, clinicians, educators, researchers, associations, and organizations have worked independently and collaboratively to improve patient safety. For example, in an effort to eliminate one of the most common causes of medication errors, medical notations, the Institute for Safe Medication Practices (ISMP) developed a "do-not-use" abbreviation list. The U.S. Food and Drug Administration recommended that the ISMP list be referenced whenever medical information was communicated, and the Joint Commission on Healthcare Accreditation (JCAHO) required that accredited organizations do not use abbreviations on this list. The notation of qd (daily), which has been mistaken for qid (four times a day), can no longer be used. Daily must be written (ISMP, n.d.).
Home care organizations face special challenges in implementing an effective patient safety program. Patients reside in unpredictable environments (their homes) and receive care from multiple healthcare providers, with most care being provided by the patient and family. Considering the unique environment of home care patients, all approaches used to promote patient safety in institutional settings may not be appropriate for implementation in home care organizations. Important lessons learned from the institutional patient safety work include the value of a nonpunitive environment and a systematic method of problem solving (root cause analysis) using a multidisciplinary team. A barrier experienced by home care and institutional settings involves the availability of a standardized data collection system.
Safety has many facets. Resources are available to assist home care organizations in the development of standardized data collection methods, root cause analysis, and identification of strategies. You may find the Web sites in the sidebar useful in addressing systems improvement and in providing evidence-based patient care. Although much of the patient safety work has focused on hospitals, many of the tools can be translated for use in the home care setting. The articles in this special issue were selected to provide organizations and clinicians with pragmatic information on a variety of patient safety topics. Future issues will continue to incorporate articles that will offer valuable patient safety information.
There is much we do not know about patient safety in home healthcare. What aspects do you think are missing? What other strategies might be valuable? Safety and quality cannot be separated. You have the ability to improve the safety of your patients and to impact the future of your organization. How will you work to improve patient safety? Dr. Lucian Leape, a tireless leader in the patient safety movement, said, "The best system in the world will not work[horizontal ellipsis]with people who do not have a sense of responsibility for one another and for themselves" (Buerhaus, 2001, p.76).
Selected Resources
* A comprehensive list (with Web links) of clinicians and health organizations, employers and consumers, foundations/research, government agencies, and quality organization is available on the IOM Web site at http://www.iom.edu/CMS/8089/14796.aspx.
* In 2003, the National Patient Safety Goals were introduced by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and an online resource was created on patient safety practices for healthcare providers and the public. The site (http://www.jointcommission.org/PatientSafety/PSP/) offers recommendations on how to meet the Home Care National Patient Safety Goals, such as those related to communication between caregivers and patient medication.
* The Centers for Disease Control's Injury Center (http://www.cdc.gov/ncipc/duip/fallsspotlite.htm) provides caregivers and patients tools to prevent falls.
* AHRQ Patient Safety Network (PSNet) features resources, news, and literature on patient safety. Sign up for free weekly updates at http://psnet.ahrq.gov/index.aspx.
* AHRQ's WebM&M (http://webmm.ahrq.gov/) monthly journal includes user-submitted cases of medical errors, commentaries, and perspectives on patient safety. On AHRQ Web sites, search using "home care."
* Another useful site was developed by the Centers for Medicare and Medicaid Services (CMS) and the Medicare Quality Improvement Community (MedQIC). At the macro level, MedQIC (http://www.medqic.org) gives expert advice in redesigning processes and transforming organizational culture. A home health site offers the capability of searching for tools, literature, stories, resource links, measures, and presentations specific to improving quality in home care.
* Patient-centered care involves including home health consumers in safety issues. Safety information for consumers can be found at http://www.nlm.nih.gov/medlineplus/patientsafety.html.
* Funded by the US National Library of Medicine and the National Institute of Health, MedlinePlus provides a variety of patient education information (English and Spanish), including fact sheets on medication safety.
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