Patient Safety in the Current Health Care Environment

Patient safety improvement continues to be an important and time-consuming aspect of every health care organization’s focus. Although some efforts have shown increases in safety and reliability in specific areas of care delivery, sustained measureable increases in overall patient safety over the past decade have been elusive despite the vast resources allocated for improvement efforts. This issue of Western Journal of Nursing Research (WJNR) includes contributions by authors whose research collectively involves principles posited by patient safety experts as core to making improvements in patient safety. The selection of articles makes the case for a return to those principles that cross the boundaries of specific failures and types of interventions and that are essential for relevant, effective, and sustainable improvement in safety.

“Failure to understand the complexity of work.” I had never considered this factor, nor heard of it being considered, in relation to patient safety during my first 28 years of nursing experience in various roles and several health care settings. Then, two human factors–focused researchers, one an anesthesiologist and the other a human factors scientist, explained to me that an overwhelming contributor to medical error was the failure to understand the complexity of work. Until recently, the goal for patient safety–focused work in health care was often, if not always, to get people “to do what they were supposed to do” in providing care, usually as outlined in policies and procedures. And the approaches for achieving this goal were usually through educating staff about the “right way” to do something. Sometimes, we designed new forms to cue staff or required additional documentation to support what we wanted to be done correctly, convinced these steps would result in the correct care being delivered. Despite numerous attempts to make sure “things went right,” the same errors continued to happen and there was no evidence to demonstrate a sustained decrease in error.

And then the Institute of Medicine (IOM) report, “To Err Is Human: Building a Safer Health System,” was released in 2000 (Kohn, Corrigan, & Donaldson, 2000), when multiple factors and the early stages of what we now understand as overwhelming complexity began to converge. These factors included technological advances, increasing population of older adults and those with chronic illnesses, higher acuity both in and out of acute care settings, a shortage of health care professions staff and providers, escalating need for care coordination, economic pressures on health care providers to decrease costs, and most recently, passage of the Affordable Care Act.

Health care literature since the IOM report has included much research and a focus on human factors (e.g., human memory, distractions), frameworks to explain how failure is generated (e.g., Swiss cheese), technology (e.g., bar coding, physician order entry, electronic medical records), and process-focused improvements (e.g., standardized communication rubric- Situation, Background, Assessment, and Recommendation (SBAR) ; safety culture), all efforts intended to understand and decrease errors and to improve safety. Measurement of the progress from these efforts continues to be complicated by lack of reliable error reporting processes, failure to sustain gains realized, and the ongoing and escalating increase in complexity and change as these improvements have been initiated.

As the economic implications of failure (e.g., patient falls, skin breakdown, wrong-side procedures, re-admissions) have increased in recent years, more attention has been paid to holding individuals accountable and identifying and dealing with risky behaviors. Less attention has been paid to the complexity that individuals encounter in the midst of care situations or the attempts they employ to manage the complexity.

Although the multifaceted nature of paths to failure is apparent, there are common areas for focus and attention that span error events and are important for guiding efforts to improve patient safety. Woods and Cook (1998) proposed five basic principles that are essential to understand for guiding successful improvements in patient safety:

Three of the articles in this issue demonstrate clearly the influence of systems and interacting components that contribute to the failures currently experienced in health care. The article by Powell-Cope and colleagues reports outcomes from an intervention for individuals with peripheral neuropathy to test the effectiveness of group exercise on gait and balance. This research will have implications for future study of innovative multifaceted approaches to increasing the balance of individual health care clients, one of many dynamic components of the complexity surrounding falls and necessary for successful fall prevention. Two additional articles report findings that demonstrate complexities of care delivery with implications for system design and care delivery models. Kalisch reports on her ongoing and evolving research related to missed nursing care. Kalisch and her research colleagues have contributed to an increased understanding about the multiple factors surrounding omission of nursing care, turning the focus of such errors away from individual nurse intent to provide less than adequate care to the system complexities and trade-off decisions necessary for coping with current care delivery challenges. Research methods that uncover information for understanding the complexity of nursing work are highlighted in the article by Sitterding and colleagues. The findings reported resulted from detailed nurse interview transcripts following direct observation during medication administration, a nursing practice function allotted enormous attention and resources given the error frequency and consequences. The findings reveal the remarkably invisible system and work complexities surrounding, and yet unrelated to, medication administration, complexities that are inherent in nurse work routines and our current delivery environments.

Cornell and colleagues’ article contains findings from research about communication, a factor found to be one of the most common contributors to failures in health care delivery. The authors report on outcomes from implementation of a structure for interdisciplinary rounds. Their efforts represent one of many different approaches currently underway to solving communication breakdowns during transfers of care and toward managing the dynamics of individual components and interactions at play during communication of patient information.

Finally, Talsma and colleagues propose a model for guiding improvement efforts toward sustainable interventions designed for use in clinical settings. Development of tested models that prove to be useful for multiple types of improvement and implementation efforts in clinical settings is needed to provide some consistency for approaches to the ever-changing systems that require people to change and adapt constantly.

Most of the improvement efforts over the past 14 years since publication of the IOM report have represented reasonable and well-intended attempts toward increasing patient safety. What continues to be difficult to grasp for those of us in health care is that improvement in patient safety will always be limited by the extent to which we understand the complexity of work. This complexity will never be solved by one process improvement, one enhanced form, or one piece of new technology. Patient safety at any one point in time is about multiple connected and changing factors, dependent, dynamically related, and yet unpredictable in the response of one to another. In fact, as many of us have learned, an improvement in one process, technology, or person can even result in unintended consequences that lead to more error events.

This special issue of WJNR highlights research and scholarship that reflect principles essential for attaining and sustaining patient safety improvement efforts. The publication of this issue comes in the context of an environment in which health care systems are initiating multiple interventions to respond to challenging regulatory and financial requirements through development of new delivery models, alternative health care provider mixes, and supportive new technologies. The danger of a rush to respond and the complexity involved in these efforts is a return to quick fixes and the abandonment of principles important for effective results and avoidance of failures.