Ten years ago this month, the Institute of Medicine shattered a widely held perception that American health care was safe. IOM’s finding that as many as 98,000 patients die each year in hospitals from medical errors launched an aggressive patient safety movement that continues today.
But the report also cast a spotlight on the role of the nurse in keeping patients safe, a role that will become even more important under the ongoing effort to reform the health care system.
Prior to the IOM report To Err is Human, there was little recognition among health care leaders of the contributions nurses make to improve quality and prevent medical errors. Although they are the caregivers who have the most contact with patients, nurses have typically been undervalued and have had to practice in an environment that often set them up for failure.
For example, a nurse working on an understaffed unit with lots of very sick patients might, in some cases, make a mistake. But the IOM report is credited with taking the blame off individual health care workers and shifting the focus to system-wide flaws that lead to errors.
Today, nurses are playing a central role in offering solutions that correct such flaws and advance patient safety and quality—throughout the system.
A chief reason for this sea-change is that nurses are starting to identify the steps they take on a daily basis to prevent errors in multiple settings including hospitals and patients’ homes. And, the quality field has started to measure and apply those error-prevention practices, like double-checking a medication order or making sure a safety check-list is followed in the operating room, to make sure patients get the best care. Most importantly, nurses are connecting the evidence accumulated in recent years with outcomes – including reducing errors, engaging patients in their care and lowering health costs.
For example, we now know that unnecessary hospital readmissions are highly sensitive to what nurses do and don’t do with patients and family caregivers. We know that good care coordination, which is managed by nurses, can affect how long a patient stays in the hospital, whether mistakes happen, and whether the patient is prepared to go home.
We also know that a poorly managed hospital discharge process, one in which the patient doesn’t get the information they need to recover safely at home, wastes precious health care dollars and puts patients at unnecessary risk of costly complications that can put them back in the hospital. In fact, one in five seniors who are discharged from the hospital return within 30 days because they or their families have not been given enough guidance in the discharge process on how to manage their illness or medications safely once they return home. The Medicare Payment Advisory Commission estimates that unnecessary readmissions costs this nation as much as $17 billion a year.
We now have the evidence to show that when nurses effectively help patients transition from hospital to home, educating both patient and family caregiver, hospital readmissions are reduced, patient satisfaction is enhanced and health care spending is decreased by as much as $5,000 per patient.
That’s a lot of money that could be directed at other worthy health care causes such as expanding health coverage to the estimated 47 million Americans without insurance.
We also have identified the nursing practices that need to change to prevent medication errors from occurring. Each year, 7,000 people die because of medication errors in hospitals. Although use of electronic prescribing tools helps reduce this problem, researchers have shown how the practice environment and level of nurse staffing affect error rates and drive up health costs. Nurses are identifying the steps that need to be taken to find medication errors early.
What they’ve learned is that when hospitals foster work environments that let nurses focus on safety interventions without fear of being constantly interrupted because there is inadequate staff to handle non-clinical matters, errors are reduced and the quality of care is improved. Imagine a nurse trying to reconcile a patient’s medications and being interrupted every 45 seconds for tasks that could have easily been done by other staff. These are the kinds of interruptions that often lead to medication errors, medical complications, and longer stays.
In addition, when hospitals create a culture in which nurses feel free to speak up about whether a prescribed dosage is appropriate or question a course of treatment, a teamwork approach to care is fostered, a model the IOM report linked to high quality care.
Helping hospitals determine appropriate staffing is another area where nurses are making inroads. Research is showing that having more highly educated and experienced nurses on staff is crucial to prepare patients for a safe discharge. Well trained and experienced nurses can also reduce infections and complications that can lengthen hospital stays among the tiniest babies in the intensive care unit (ICU).
Despite these pockets of progress, nurses are still undervalued as quality and safety champions. They constantly have to fight to be included in decision-making roles in hospitals and other health care settings. Even today, only 2 percent of hospital boards – where major decisions about safety, quality and health system redesign are made – have nurses sitting on them. This, despite the fact that nurses account for more than half of all health professionals and are spearheading efforts to reduce bloodstream infections in ICUs, prevent medication errors, and better coordinate care.
If we are to move forward, we must do a better job of providing policymakers, health care leaders and the public with the evidence showing the link between nursing care and patient safety. Any health care reform legislation must support the role of nurses in building a better system that provides the highest standard of care that is not only safer but is also likely to save money.
One key step would be to eliminate regulatory and other barriers that make it hard for nurses with the right skills to provide care that has been linked to better outcomes. And reform bills should foster quality and payment incentives that maximize the solid contribution of nurses on the front lines of the health care crisis.
Is American health care safer today than it was ten years ago?
Yes, but the health system can still make improvements, and the nurse, now more than ever, needs to be at the center of the ongoing safety revolution.
Mary Naylor is the Marian S. Ware Professor in Gerontology at the University of Pennsylvania School of Nursing; Mark Pauly, is a health economist and the Bendheim Professor at the University of Pennsylvania’s Wharton School. They co-direct the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative.