It’s a fact of life: Mistakes happen. When those mistakes involve medical errors, however, the costs can be devastating to patients, families, and healthcare providers. No one is infallible, but healthcare professionals have a responsibility to understand issues related to patient safety and foster a culture of safety within their organization.
A brief history of patient safety
Established in 1951, The Joint Commission is a leading independent nonprofit organization dedicated to improving patient safety in healthcare environments worldwide.
Best expressed through their National Patient Safety Goals, The Joint Commission works to illuminate high-priority patient safety issues—like preventing hospital-acquired infections and medication errors, maintaining safety during surgeries, ensuring correct patient identification, enhancing communication between staff, and identifying patients at risk for suicide.
A nurse wheels a patient into the surgical suite for a partial mastectomy on her right breast. The surgeon—whether due to exhaustion, poor communication, or misunderstanding—prepares for surgery on the patient’s left breast. A surgical nurse notes the discrepancy and calls for a time-out to clarify, thankfully sparing the patient a wrong-site procedure.
This is an example of a “never-ever event.” First introduced in 2001 by Dr. Ken Kizer, former CEO of the National Quality Forum, the term is used to describe especially shocking medical errors (such as wrong-site or wrong-patient surgery) that should never occur.
In most cases, a never-ever event will have three main features. First, it is an unambiguous event. No one would argue, for example, that leaving a piece of equipment in the patient’s body after surgery is a positive outcome. Second, it is a serious event. The human body does not function well with pieces of gauze or broken instruments inside it. Finally, a never-ever event is usually preventable. A careful inspection of the surgical tools beforehand, paired with a thorough check after the procedure, would have likely spared the patient this never-ever event.
Hospital-acquired conditions (HACs)
Some patient safety issues are unique to the hospital setting. From human error to lax hygiene practices to missteps due to understaffing, these conditions can be life-threatening and often fall into the “never-ever” category. Some of the most common hospital-acquired conditions are:
- Foreign objects retained after surgery, also referred to as unintended retention of foreign objects (URFOs) or retained surgical items (such as sponges, towels, needles, or broken surgical instruments)
- Intravascular air embolism, where air trapped in the arterial or venous circulation blocks blood flow
- Blood incompatibility, where a patient receives incorrect donor blood, causing their immune system to turn against the donated blood
- Falls and trauma, an HAC that’s most common in older adults but can occur in patients of any age, dependent on pathophysiology and medication
- Poor glycemic control, where blood glucose levels are improperly managed
- Catheter-associated urinary tract infections (CAUTIs)
- Vascular catheter-associated infection
Checking all the boxes
Effective patient safety practices begin with clear, well-documented communication standards, rigorous hygiene, and simple vigilance. While checklists may be onerous, they can save lives. For example, a healthcare provider may want to ask the following questions before, during, and after a procedure:
- In the surgical suite, has the patient’s identity been verified using two different forms of ID?
- Have all members of the surgical team followed proper hygiene guidelines?
- Does the patient’s medication have clear labels? Do they have any allergies or pre-existing conditions?
- As the patient prepares for discharge, have the requirements relating to their medication been explained to them in ways they can understand?
Taking the extra minute to ensure compliance with standard safety procedures is time well spent. For a patient, those few extra minutes of care may be the difference between life and death.
This article was adapted from our sister site, Elite Learning, written by Adrianne E. Avillion, D.Ed., RN.