The Patient Safety Challenge
Deborah Halinski

Deborah Halinski, RN, CNN, CPHQ, is Performance Improvement Specialist/Nurse Manager, at Winthrop University Hospital, The Dialsysis Center at Bethpage, in Bethpage, NY. She is a member of ANNA’s Long Island Chapter.

Five years ago the Institute of Medicine brought patient safety to the forefront with its report, “To Err is Human, Building a Safer Health System” (Kohn, Corrigan, & Donaldson, 2000). Health care providers across the nation are accepting the challenge and have been making strides in creating an environment centered on patient safety.

Why is patient safety so important to our profession? It is part of the pledge we make when we enter nursing. In part, the Florence Nightingale Pledge states, “I will do all in my power to maintain and elevate the standard of my profession...and devote myself to the welfare of those committed to my care.” It is this commitment that puts nurses on the frontline of all patient care and gives us the responsibility for educating, advocating and ensuring that safeguards are in place and being used to promote patient safety.

A “Blame-Free” Environment
Our institution, Winthrop University Hospital, has embraced the task of improving patient safety and made patient safety a priority. In our nephrology network, we formed a Patient Safety Committee, made up of department staff at all levels starting with the Division Chief, Medical Director, Nurse Managers and Floor Staff. This group developed a “Core Philosophy.” There are five key points to this philosophy that have been incorporated into inservices and newsletters. One point that has been highlighted is: “We promote safety by improving processes, systems and communication, not by blaming individuals.” We have stressed the importance of staff accountability in a “blame-free” environment and have seen an increase in reporting of actual and potential adverse events. We believe this can be attributed to staff “buy in” to a blame-free environment. Our Departmental Safety Committee also reports through our institution’s safety committee.

In the Renal Services Department, we began our patient safety initiative by conducting a survey to ascertain how staff felt about human factors that affect patient safety. The survey results helped guide us in our educational endeavors and program development.

Launching the Initiative
Our initial step to launch this initiative was providing staff inservices. The topics covered were: review of survey results, background of patient safety initiative, human factors that affect patient safety, and what can be learned from event and near-miss reporting. In addition, we reviewed appropriate reporting forms specific to our institution. To further increase compliance with reporting, hanging folders with appropriate forms were placed throughout all units in easily accessible locations. These completed forms, as well as tracking/trending data are reviewed by the Safety Committee on a monthly basis. Changes in some practices and processes have been made as a result of these reviews. Staff input has been instrumental in fostering change and it is wonderful to see staff empowered in this way.

Additional education includes quarterly staff newsletter highlighting safety concerns, feedback to safety alerts, summary of unexpected adverse events and recommendations from the Safety Committee. We have also encouraged “Brown Bag Day” for medication reviews and supplied staff with bags to distribute to patients when it is time for reviews.

Patient Involvement Is Necessary
Patient involvement is necessary for the success of this initiative. To facilitate this, an informational flyer was developed and distributed to patients. We were able to have more patient involvement, in some locations, by using patient representatives to assist in the distribution of this flyer. The flyer outlines what we, as health care providers, and what patients can do to ensure patient safety. To emphasize the importance of patient safety, we promoted National Patient Safety Awareness Week in March 2005. Posters were displayed and educational materials regarding patient safety were provided.

We are making progress in a journey that is sometimes slow. We have hit some bumps in the road but our staff has embraced this challenge and is committed to do all in their power to ensure the safety of those under their care. Therefore, we challenge others to do the same!

References
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: Committee on Quality of Healthcare in America, Institute of Medicine.