Introduction and background
Patient safety has always been the heart of healthcare practice and nursing through the history of medicine. However, all through the world occasional non-deliberate accidental harm occurs to patients looking for care. Such unfavourable incidents can occur at all levels of healthcare whether clinical or managerial, curative or preventive, and in general healthcare, or private. It may occur at any stage of management (radiology, laboratory, operating room, ward, or ICU).
The WHO, at the meeting held on July 2006, in New Delhi, India, identified an adverse event as a separate unconnected incident associated with health care, which results in in-deliberate injury, illness, or death. Such incidents can be preventable as with contaminated injections.
Published surveys on patient safety show that in industrialized advanced countries, more than half of these adverse events are preventable and occur because of a shortage in system or organization design or operation rather than because of poor performance of healthcare providing staff (WHO report, 2006).
Harvard Medical Centre study in 1991 (after WHO report, 2006) was the first to draw the attention to the volume of patient safety problem. Based on medical records review, the rate of adverse event in three US medical centres ranged between 3.2 to 5.4 percent. In UK, the rate was 11.7 percent and in Denmark, the rate was 9 percent (WHO report, 2002). Results of recent studies suggest the rate is between 3.2 and 16.6 percent (per 100 hospital admissions). The situation in the less well-documented health care centres in the developing countries is more serious (WHO report, 2006).
The cost of adverse events that endanger patient safety can be very high, considering all the aspects. It includes, loss of confidence and credibility and reputation of health care institutions, loss of enthusiasm and job gratification among the working staff. In addition, the cost includes damage to the patients and their relatives especially when taking defensive attitudes and keeping information hidden from patient’s families. Other added costs are those of prolonged hospital stay and increased medical expenses and those of lawsuit demands (WHO report, 2006).
The objective of this paper is to review, in brief, the problem of patient safety with particular attention to patient safety in the ICU being one of the essential patient care systems in a health care organization. Besides, the vulnerability of ICU patients augments the importance of patient safety concept.
This thesis is a literature review study. The researcher performed an article search using the following internet databases:
- National Centre for Biotechnology – National Library of Medicine – National Institutes for Health (NCBI), at
- Medscape database, at
- Amedeo: The Medical Literature Guide, at
- British Medical Journals, at
- World health organization – Publications, at
- Yahoo and Google scholar general databases, site of .org, .gov and.edu only considered.
Terms of search were patient safety, basics, and principles of patient safety, review of patient safety, patient safety in the ICU and the critically ill patient safety.
Patient safety event is a wide term; it does not only mean a medical error during the course of medical management and nursing. The Department of Health and Human Services, 2008, defined a patient safety event as an incident, which takes place during providing a health care service.
It causes or may have caused a harmful outcome to the patient. It includes errors of not doing (omission) or errors of doing (commission), it also includes faults and mistakes of the patient care processes (involving drugs and equipment’s) or the environment where these processes are carried out.
The phrase, one cannot manage what cannot be measured hold true for patient safety. One of the reasons of the lack of effective patient safety strategies is the need for a measurement tool to provide measures, consequently, reduce medical errors and improve patient safety.
The Agency for Healthcare Research and Quality (AHRQ) developed an array of Patient Safety Indicators planned to screen administrative data for events related to patient safety. This list of indicators includes 16 situations where a threat to patient safety may occur during the course of healthcare delivery. Using this measurement tool shows that patient safety incident of highest rates are failure to rescue, decubitus ulcers and postoperative wound infection (which is specifically increased by 35% during the period 2002-2006) (Health Grades Inc, 2006).
Infection control: An important part of patient safety
Bruke, 2006, has provided a comprehensive review of infection control as an important aspect in patient safety strategy. Based on many studies, hospital acquired infection; in this context, alternatively called health care associated infection, is one the most frequent risks for patient safety in patients admitted to hospitals. The answer to the question of why it is an important aspect for patient safety lies in the fact that 5-10 percent of patients admitted to acute care hospitals acquire one or more nosocomial infection. In the US, 2 million patients acquire hospital infection every year with 90.000 deaths.
This adds a cost of 4.5 to 5.7 billion US $ to the health care cost (Bruke, 2006). There are four types of hospital-acquired infections, which account for 80% of the total rate. These are infection associated with urinary catheterization, blood borne infection (usually with vascular invasive procedures), surgical wounds infections, and pneumonia (usually associated with the use of ventilators). Therefore, it is understandable that 25 per cent of these infections occur in the ICU (Bruke, 2006).
The increased awareness of patient safety resulted in reorganizing the concepts of infection control and placing it in the domain of public health with consequent increased surveillance and epidemiological studies. It is true that recognizing risk factors allows clarification of what is adjustable and what is not, however modification of some terms is advisable. Instead of saying avoiding the use of catheters, we should recommend reducing the duration of use of catheters. Many other terms as use antibiotics intelligently, and training and staff education are hazy and indistinct, accordingly, tricky to employ (Bruke, 2006).
Nursing practice and patient safety
The report of the Institute of Medicine, 2004 (after Armstrong and Laschinger, 2006) recognized nursing role as pivotal to patient safety. The report suggests the degree of activity of hospital nurses and the extent of giving them authority to take part in decisions, directly affects the quality and perception of patient safety. The results of Armstrong and Laschinger, 2006 supported this assumption; they recommended that nurses should enjoy better communication and participation in decision-making. The responsibility of nurse managers, at the unit level, is even greater.
They take part to establish nursing practices, which support patient safety culture, they also sustain professional nursing practices, and they should listen carefully to nurses relevant affairs. If nursing managers achieve their direct responsibilities, then they work with others in the healthcare establishment to make the organizational process better as regards limiting the nurse’s competence towards better patient care. The result of Armstrong and Laschinger, 2006 suggested that nurse managers (nurse leaders) have the capability of developing patient safety in healthcare organizations.
Medication management and patient safety
Duthie and colleagues, 2004, analyzed the 108 reports submitted to the New York State Department of Health investigating the medical errors in New York State healthcare organizations. From quantitative viewpoint, their results suggested that nursing the first discipline to be involved in such errors and they provided the explanation that nurses are the end dispenser since they give the medications to patients directly.
In addition, they showed that patients over 65 years are the most vulnerable to these errors, perhaps because of the increased number of medications prescribed at this age. From a qualitative viewpoint, they suggested that what may endanger patient safety is dispensing system malfunction, failure to rescue situations and working space limitations. They suggested the need to educational initiatives and pointing out possible dispensing system malfunctions.
Adamski, 2005, suggested the following precautions to minimize medication errors:
- Monitoring how patients respond to medications as long as it is dispensed in the healthcare organization.
- Diagnosis and indication for a particular medication should be available in the patient’s progress notes, history or examination sheets.
- Clear order forms to dispense medications in order to ensure clear and mutual understanding among the prescribing physician, pharmacist, and thenurse who administers the medication.
Davis and colleagues, 2006, examined the patient role in medication errors. They suggested that low literacy patients (up to 6
grade level) are more liable to misunderstand medications label instructions. However, they suggested that lower reading and writing skills and high number of medications prescriptions link separately to misunderstanding of instructions on medications labels.
Hospital design and device purchase in patient safety strategies
Reiling, 2005, suggested that building a hospital (whether new or relocated) around the principles of patient safety would have two important impacts on return of investment. First, it combines safety and efficiency, second, it reduces the costs of adverse effect and hospital stay therefore; reduces the patient’s cost on discharge.
To achieve a safety cantered hospital design, Reiling, 2005, suggested that architects, engineers, contractors, heads of departments and executive managers should participate in discussions around what they need. There is no specific design but contributions of the whole team from the perspectives of patient safety culture are mandatory.
Johnson and colleagues, 2004, examined the patient safety in purchasing equipment. They analysed purchasing decisions taken at three different healthcare centres. Johnson and other, 2004, assumed there were points of strengths and others of weaknesses. The points of weaknesses draw the attention to the necessity of having guidelines to help healthcare providers to assess issues of patient safety when purchasing medical devices.
Patient safety in the ICU
There are many reasons that make the ICU a special unit to look at specifically as regards patient safety. Of these reason, the patients are critically ill, which renders them vulnerable to the adverse effect of medical errors. Second, the great effort performed by nurses and internists with sometimes exhaustive shift work, which may result in sleep deprivation and possibly lack of concentration.
Third, the diverse use of equipment (ventilators, catheters, monitors etc) and the invasive procedures sometimes adopted (emergency tracheotomy, central venous pressure or arterial-venous cannulation) which add to the risk of hospital-acquired infection or increase the incidence of adverse effects (Rothschild and others, 2005).
Rothschild and colleagues, 2005 conducted a one-year prospective observation study as a part of Harvard Hours and Health Study (2002-2003). They designed their study as a multidisciplinary epidemiological study to portray both frequency and types of adverse effects in the ICU. The result were informative, there were 120 adverse events reported (80.5 per 1000 patient-day). Of the patients who suffered adverse effects, 13.8% suffered one adverse effect, and there were 16 life-threatening adverse effects.
The commonest were respiratory, infection, and cardiovascular system (19%, 15%, and 12% respectively). The incidence of serious medical errors was 149.7 per 1000 patient-day of which, 11% were life threatening. Incident discovery was by direct observation in 62% of the cases and the patient’s nurses discovered 36 % of the cases. In 74.8% of cases, errors occurred during the course of treatment or a procedure.
An intern failure to wash hands after attending a patient formed 51% of sterility hazards related to procedures. Although their results cannot be applied to all ICU units, yet it draws the attention to how frequent and how serious patient safety can be compromised in ICU units. At the same time, their result show how results of treatment in the ICU would improve, despite the hard work, if teams stick to unit protocols and principle of patient safety (Rothschild and others, 2005).
Kho and others, 2005, used the Safety Climate Survey (a tool approved by the Institute of Health Care Improvement) to measure patient safety in four ICU units, 56.9% of those responded to the survey were nurses. Based on their results, they assumed that Safety climate survey and Safety culture scales are reliable tools to measure patient safety in ICU.
Chang and other, 2005, suggest that reform of patient safety in the ICU should start by establishing physician and nurse leadership, once this is achieved, carrying out patient safety protocols becomes a matter of team effort and commitment to the concept. Identifying a specific group of patients to start with (as an example, patients on ventilators), planning carefully the procedures, and opening a communication channel among the staff should reach the best results.
Following evaluation of what progress made, the next move is for another group of patients. At the end, this should provide synchronization among the staff that makes decision making in shortage of time easier and provides better training and education to the newly coming staff.
Obstacles facing the implementation of patient safety
Cook and colleagues, 2000, considered the complexity of healthcare as an overwhelming obstacle to achieve desired patient safety levels. Technical work in healthcare needs appropriate and quick decision making, critical to the patient’s safety at times, moreover, it is risky by nature. It is true that health practitioners whether physicians, nurse, technicians or other staff are trying to cope with this complexity, however this complexity creates a disparity in healthcare practice and nursing (they called it gap).
Cook and colleagues assumed the means of improving patient safety is by supporting practitioner’s ability to perceive and cross these disparities, rather than making changes in authority or different roles with possible division of professional work force. The search and detection of these disparities or gaps as a research goal should make the breakthrough in patient safety achievements. During this research pursuit, disparities indicate areas of weaknesses and susceptibility and may elicit the means complexity flows through health care systems to patients (Cook and colleagues, 2000).
Amalberti and colleagues, 2005, identified five system barriers to even safer healthcare; the first is regulations, which significantly limit the risk allowed, thus, limiting maximum performance of healthcare givers. There is a real need for proper balance between the industrial notions to get a high productivity whatever it takes, and the concepts of patient safety culture. Doing that, researchers should take into consideration the economic troubles of the healthcare system and the spontaneous drive of productivity among healthcare workers.
Second, other important issues need dealing with before or in conjunction with the issue of patient safety, an important example to these issues is the need for standardization of healthcare practice and nursing. Third, the core of healthcare work is synchronization among practitioners, therefore recommendations should stress on teamwork and opening communication channels among the healthcare staff, instead of trying to reach optimal performance of each organizational level separately. The fourth obstacle is the need for system-level mediation to improve patient safety planning.
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