Tuesday, December 1, 2009

Where do nurses stand 10 years after the IOM Report “To Err is Human”?

To Err Is Human Blog Series Logo

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

INQRI Co-Directors Mary Naylor, the Marian S. Ware Professor in Gerontology at the University of Pennsylvania School of Nursing, and Mark Pauly, the Bendheim Professor at the University of Pennsylvania’s Wharton School, offer their perspectives on how that report affected safety, front-line nurses, and practice culture.

What impact did the IOM report have on advancing safety?

Mark Pauly: I don’t think anybody really knows for sure. The estimate of the number of deaths due to errors was based on taking an old study and extrapolating it nationally. Measures are better now but to some extent we are still in the dark in terms of what we do know for sure or what the baseline is for the number of medical errors. It definitely raised the profile of medical errors and showed how it is a relatively important measure of quality as compared to other measures. There is much more of a concern now about errors than there was in 1999. Excuses for medical errors are now passé. Today, there are no excuses. It mostly changed the nature of the discussion by focusing much more on errors as a measure of quality and offering it as an objective.

Mary Naylor: The report made us pay more attention to the importance of the work that nurses do at the bedside as it relates to medical errors. Nurses mobilized and as a field we began to seriously try to identify measures that captured what nurses do day-to-day to keep patients healthy. An important example of that is the National Quality Forum’s (NQF) 2004 endorsement of nurse-sensitive measures. These were explicitly focused on issues around errors and avoidable events and there was the beginning of a sense that nurses are central to what happens to people in the hospital and other health settings. We finally had a group of quality leaders who said, ‘let’s define robust measures and constantly monitor those efforts.’

Did the report focus on the right problems?

Mark Pauly: Calling attention to errors is important. But the basic thrust was to blame it on the system and treat people as cogs in the mechanism. We’ve gone too far in characterizing it as a system failure that has nothing to do with people. The IOM report downplayed the role of the nurse even though the nurse is involved in the actual delivery of care. Nurses are almost always there and are in a position to notice that something hasn’t gone right but feel intimidated to bring that to someone’s attention. They also have a lot to contribute to system redesign. I feel they haven’t been consulted much on the system design issues over the decade.

Mary Naylor: The first set of nurse quality measures from NQF provided a good start at focusing on all the things that could go wrong with patients such as failure to rescue, pressure ulcers, falls – things that nurses very much are concerned about and if not handled appropriately could contribute to poor outcomes. But they didn’t capture what nurses do right or what they do to prevent those things from happening in the first place. The focus on errors did push people to look at how we measure those things but it didn’t really focus on what nurses do to intercept those errors. All of this has led to the establishment of a quality alliance focusing specifically on nursing, which will launch in 2010. This is really important because we now have a group of stakeholders agreeing that nursing is central to the prevention of medical errors.

The big word in health care today is “teamwork” – a term promoted in the report. Is teamwork making a difference in quality/safety and are nurses now seen as an equal member of that team?

Mark Pauly: It does seem that while everyone is promoting this idea of teamwork in healthcare, the doctor is still the leader whose decision matters. Nurses have a central and essential role to play on the team but that recognition is just now coming and it hasn’t really had much of an impact yet.

Mary Naylor: We are only beginning to see some evidence in which the role of nurses is being considered and largely valued. The challenges around care coordination have placed a positive spotlight on nurses as key in helping to identify what information is most vital to be communicated from one person to another or from one site to another. However, nurses are rarely consulted on these important communications. We are seeing much more appreciation that nurses should be a major part of any effort to redesign care coordination but that recognition is not consistent, comes late in the game and is something we as nurses have to fight for all the time.

So where are nurses’ voices being heard when it comes to promoting patient safety? What has made a difference for nurses?

Mary Naylor: Having evidence to show what interventions work makes a difference. The strength of the evidence from research has made us successful in getting provisions in the current health reform bills that reflect nurse-led interventions. For example, the existence of irrefutable evidence in transitional care has been the central reason we cannot be dismissed anymore because we now can show what nurses contribute to quality care and what that contribution means to costs.

Mark Pauly: Concrete examples of nurses’ contribution to care coordination are important. But what gave nurses leverage was when care coordination got translated into the readmission rates and policymakers started to notice that it mattered for cost and outcomes. That is what changed the conversation. One of the things we are doing at INQRI is starting to generate and link regulation and policy behind the research we’re producing.

Mary Naylor: We need to be providing the same kind of evidence around end of life care, where nurses are the true caregivers. Nurses have played a critical role in engaging patients as family caregivers, even in convening around advance care planning and ensuring access to palliative care. Long term care is the next crisis on the health reform agenda. The long term care debate represents a huge opportunity for nurses through evidence to show their capacity to prevent unnecessary hospitalizations and enable patients to have a much higher quality of life.

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