Nurses Are Key to Improving Patient Safety

The Institute of Medicine's Future of Nursing report points the way toward more nurse leadership and system-wide culture change, which can help reduce medical errors.

    • April 28, 2011

Aline Holmes, M.S.N., R.N., still remembers the 23-year-old motorcycle crash victim who came into the emergency room at the teaching hospital where she worked some 40 years ago. A resident allowed a medical student to change the patient’s tracheotomy tube—a delicate procedure given the facial fractures and complications the patient was experiencing, and one that Holmes believed required a more experienced hand. Holmes was at the bedside when the procedure went horribly, perhaps predictably, wrong, and the patient quickly died. Horrified, she quit that job the next day. Today Holmes devotes her career to improving patient safety and the quality of care.

It should be a given that the health care system makes people healthier but, in practice, often that is not the case. More than a decade ago, the Institute of Medicine (IOM) issued To Err Is Human: Building a Safer Health System, stunning many with the conclusion that as many as 98,000 people die in U.S. hospitals each year as a result of preventable medical errors. The consensus view is that improvement since then has been slow at best. In announcing a new patient safety initiative this month, the U.S. Department of Health & Human Services reported that at any given time, about one in every 20 patients has an infection related to their hospital care—and, on average, one in seven Medicare beneficiaries is harmed in the course of their care.

For nurses, the issue is fraught with challenges. As front-line providers, nurses stop errors, feel powerless to stop errors, make errors, and may at times be blamed for errors they did not commit.

The kinds of errors that both involve nurses in some way and endanger patients cover broad territory. This territory spans “wrong site, wrong patient, wrong procedure” errors, medication mistakes, failures to follow procedures that prevent central line bloodstream and other infections, errors that allow unsupervised patients to fall and more. Some errors can be traced to shifts that are too long and leave providers fatigued; some result from flawed systems that do not allow for adequate checks; some are caused by interruptions to nurses while they are trying to administer medications or provide other care. Many, experts say, come from a culture that can leave nurses powerless to intervene when doctors or others commit errors.

Holmes has seen all that and more as director of the New Jersey Hospital Association’s Institute for Quality and Patient Safety and senior vice president of the association. She also leads the New Jersey Transforming Care at the Bedside program (TCAB)—a quality improvement initiative funded by the Robert Wood Johnson Foundation (RWJF) that encourages nurses to suggest, implement and evaluate safety-related changes in their units. The New Jersey TCAB stems from a successful nationwide program that was administered by the Foundation and the Institute for Healthcare Improvement.

“Patient safety and quality have not been part of the education of nurses, or of physicians,” Holmes said. “Today, nurses are taking a much more pro-active role, but we still have a long way to go.”

“Nurses still face enormous challenges when trying to advocate for patients,” agreed Mary Jean Schumann, D.N.P., M.B.A., R.N., C.P.N.P., executive director of the Nursing Alliance for Quality Care (NAQC), a Foundation-funded partnership among the nation’s leading nursing organizations and consumer groups. “It’s a serious problem. We have to look closely at what is happening to providers of care in environments that put patients at risk.”

Schumann talks about the “moral distress” a nurse may feel, for instance, in seeing a surgeon rushing through, and skipping parts of, a safety checklist—and the “moral courage” it can take to speak up. “A nurse who intervenes can make that surgeon very angry. You are vulnerable when you blow the whistle.”

Holmes concurs. “When a nurse has to stop a procedure, she or he has to be able to reach someone with power, even a hospital CEO, who will reliably provide back up. We’re not trained for this, but we need to be empowered. There’s often a gender dynamic and a power dynamic that makes it hard for nurses to be assertive.”

Nurse Leadership Needed

The IOM’s 2010 report, The Future of Nursing: Leading Change, Advancing Health, addresses patient safety in myriad ways. Based on the work of the Com­mittee on the RWJF Initiative on the Future of Nursing, the IOM report is a thorough examination of the nursing workforce. It offers a series of recommendations to transform the nursing profession to better meet the nation’s health care needs.

The Future of Nursing report’s recommendations on nurse education, research and leadership all point to an expanded role for nurses in improving patient safety. For instance, if implemented, its leadership recommendation—that nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States—would help empower nurses at all levels to contribute to improvements in patient safety. The report calls for more advance practice registered nurses (APRNs) and more nurse-led research into ways to improve the quality of care.

“This report provides the support and direction for nurses to assume more leadership responsibility in the redesign of our health care system,” Holmes says. “Solutions lie in a team-based approach, not everybody following the orders of the captain of the ship.”

Schumann also touts shared decision-making and better communication as effective strategies, and says it “comes down to the culture. Everyone needs to be heard.” Too often, she notes, nurses are not in the room when solutions are devised and are brought in only when it’s time to talk about implementation. Even when nurses are included in problem-solving, “a single nursing voice is not enough,” she cautions.

Holmes says nurses need to push themselves as well. “We need to get out there, develop more leadership skills—but top leadership needs to support that too. They need to focus on quality and safety, and bring nurses into those conversations.”

In addition to TCAB, the Robert Wood Johnson Foundation supports a number of nursing programs that fund scholars conducting research into various aspects of patient safety, and in other ways seeking to reduce medical errors. These programs include the Interdisciplinary Nursing Quality Research Initiative (INQRI)—which sponsored a blog carnival on the 10th anniversary of the IOM’s To Err Is Human report—RWJF Executive Nurse Fellows, RWJF Nurse Faculty Scholars, Partners Investing in Nursing’s Future, Quality and Safety Education for Nurses, and other programs.

AkkeNeel Talsma, Ph.D., R.N., may be the kind of nurse leader the Future of Nursing report envisions. An RWJF Nurse Faculty Scholar and assistant professor of nursing at the University of Michigan in Ann Arbor, Talsma is investigating the relationship between operating room errors and patient outcomes at discharge. Her study will contribute to an understanding of the relationship between nurse staffing characteristics, interruptions and discontinuities of care, and patient outcomes.

Talsma is part of a new generation of nurses who feel they have a mandate to evaluate data, learn from it and improve systems. “Not only do we describe problems,” Talsma says, “we say that it is unacceptable and look for ways to make changes. Perhaps it’s generational. We ask questions and don’t just accept urinary tract infections, pressure ulcers and other problems that are avoidable. We ask questions our parents’ generation might not have asked. Nurses with advanced degrees are in a position to focus on improving patient safety.”

As nurses lead complex studies, Talsma sees hope for culture change as well. Nurses “all have bad memories of being written up, or seeing someone else blamed,” she says. “Too often, when medical errors occur, we have hunted down the bad apples instead of growing better apples.” But Talsma sees a growing recognition that nurses are well-positioned to find solutions.

She may be right. Nurse-led solutions have broad support. A Gallup poll commissioned by RWJF and released in 2010 found that large majorities of opinion leaders would like to see nurses exert more influence in a number of areas, with reducing medical errors and improving patient safety (90 percent), and improving quality of care (89 percent) topping the list.

“This is a time of unparalleled opportunity for nurses and the people who rely on them for high value health care,” said Mary D. Naylor, Ph.D., R.N., F.A.A.N., INQRI program director. “The unique role and contributions of nurses has been highlighted in the IOM’s nursing report. The research being funded by INQRI and other RWJF programs is helping to build evidence about nurses’ role in patient safety.”

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