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.
More Americans die each year from medical mistakes than from car crashes, breast cancer or AIDS—so said the IOM report a decade ago. But the real impact of the report, according to two INQRI researchers, was to shift the focus from individual blame to an atmosphere of collective responsibility for patient safety.
Prior to the IOM report, hospitals kept track of medical errors, like giving the wrong drug to the wrong patient, say nurse researchers Tracey Yap PhD and Susan Kennerly PhD, of the University of Cincinnati in Ohio. Typically, mistakes were attributed to one person; therefore, that nurse might have to explain how she planned to change her practice to avoid making the same error again.
Now hospitals seek safety protocols that can prevent individual error and also have the ability to raise the quality of care provided throughout a facility, say Yap and Kennerly, who with their University colleagues Elaine Miller DNS, Jay Kim PhD, and C. Ralph Buncher ScD are working on an INQRI-funded project are examining the merits of a team approach to care. The University of Cincinnati’s College of Nursing in partnership with Signature HealthCare of Florida developed a system-wide approach to prevent bed sores or pressure ulcers, which can lead to infection and significantly higher health costs.
The group of researchers, led by Yap, knew nursing home residents needed to be moved every two hours to reduce the risk of a pressure ulcer. The intervention sounds a musical alert over the facility intercom every two hours to indicate it is time for the residents, if capable, to move or be assisted to move by facility staff. Furthermore, the program is designed to be carried out by an entire team (composed of staff from various areas in the facility—not just nursing) working together to reduce the risk of a facility-acquired pressure ulcer.
The housekeeper or another member of the health care team can assist nursing with those residents who only need verbal prompting, while nurses will continue to perform the crucial safety tasks with those who require assistance with moving. The staff member who does the task makes a note that the patient has been moved at the designated time and indicates it on the medical record.
The primary goal of the project is to reduce by 50 percent the risk that an elderly nursing home resident will suffer from a pressure ulcer. The advantage of such a system is that it spreads the responsibility for a safer environment to the team and takes the onus off a single individual, like the nurse who might be handling many duties all at the same time. In addition to reducing the risk of pressure ulcers, the researchers hope this system-wide approach will also free up the nursing staff to attend to other duties.
Today’s nurse must deal with complex patients with multiple medical problems and with an increased workload, say Yap and Kennerly, adding that often, facilities that take some of the load off a single nurse and encourage teamwork are able to provide a higher standard of care, one that keeps patients safer.
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