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NUR MISC/Patient Safety:Understanding Adverse Events and Patient Safety,100% CORRECT

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NUR MISC/Patient Safety

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nur miscpatient safetyunderstanding adverse events and patient safety

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NUR MISC/Patient Safety:Understanding Adverse Events and Patient
Safety
“First, do no harm.” This phrase is one of the most familiar tenets
of the health care profession. If you poll a group of health care
professionals, it is likely all would say they strive to embrace this
motto in their practice. And yet, patients are inadvertently
harmed every day in the health care system, sometimes with
severe consequences.

Noah Lord was one of these patients. At the age of four, Noah had
an operation to remove his tonsils and adenoids, to help with
chronic ear infections. Although it was a simple outpatient
procedure, a series of miscommunications increased his risk for
harm:

• Noah’s surgeon did not fully understand Noah’s symptoms or history.

• After the procedure, the care team sent Noah home
early, possibly without notifying the surgeon.

• When Noah’s mother called the hospital five times for help,
each time she spoke with people who failed to communicate
important information, such as critical warning signs.

Noah was at home when he began to bleed profusely from his
nose and mouth, where he’d had the surgery. Tanya Lord, his
mother, was a lifeguard and knew CPR. She was able to clear his
airway and revive him three times, but Noah eventually died
before paramedics arrived to help. In the video, she describes
how what happened changed her life forever

Adverse Events Are Common
Although the results are not always as devastating as what
happened to Noah, the reality is adverse events in health care
happen all the time. Studies of different health care settings in
the United States have found:1

,. About 1 in 10 patients experiences an adverse event

, during hospitalization.
. Roughly 1 in 2 surgeries has a medication error
and/or an adverse drug event.
. More than 700,000 outpatients are treated in the
emergency department every year for an adverse event
caused by a medication.
. More than 12 million patients each year experience a
diagnostic error in outpatient care.
. About one-third of Medicare beneficiaries in skilled
nursing facilities experience an adverse event.

The consequences of these adverse events can be physical,
emotional, and/or financial.

People Make Mistakes
The simplest definition of patient safety is the prevention of
errors and adverse effects to patients associated with health
care. 1

Patients are inadvertently harmed every day in health care
systems, sometimes with severe consequences. And some — but
not all — harm to patients is the result of human error. No matter
how well-intentioned, well-trained, and hard-working, health
professionals are human and make mistakes. Even Dr. Don
Berwick, the founder of IHI, will tell you about errors he has made

As Dr. Berwick said, “Almost anyone in that situation stood a
substantial risk of making that same error.” It’s true.

In fact, as the patient safety field has evolved, it has moved
away from the term “medical error,” which tends to
overemphasize the role of individuals in causing harm. As it turns
out, exploring the real root causes of harm means looking far
beyond individual providers; it means taking a close look at the
systems in which they work.
The Evolution of Patient Safety

, The patient safety movement started as a recognition that health
care was causing injury and death to patients in the course of
care. Today, the movement encompasses much more: designing
health care systems that reliably deliver the best outcomes to
patients at the lowest cost. (Click to enlarge the image.)

In 1999, the Institute of Medicine (IOM) released its landmark
report, To Err Is Human, which revealed that between 44,000 and
98,000 people died each year in United States hospitals due to
medical errors and adverse events.2

It did not identify the main cause of the problem to be reckless or
incompetent providers.

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