PATIENT SAFETY AND

QUALITY CARE MOVEMENT

Kristine Martin
University of South Florida

PURPOSE
Discuss the Patient Safety and Quality Care Movement
Discuss quality care concepts proposed by the Institute of
Medicine
Review types of safety errors
Recognize the significance of the movement to the nursing
profession

DEFINITION
Started in the 1970s by the American Society of Anesthesiologists

Adverse event data base

Improve mortality rate by identifying cause
Focus on prevention
Changes in education
Standards of care

GOAL: increasing patients safety by improving the quality of

healthcare provided to them

DEFINITION
The Institute of Medicine considers patient safety
Indistinguishable from the delivery of quality health care
Quality:
The degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current
professional knowledge

Patient safety:
the prevention of harm to patients.
prevent errors
learn from the errors that do occur
built on a culture of safety that involves health care professionals, organizations, and
patients

INSTITUTE OF MEDICINE CONCEPTS

3 Phases of the Quality Initiative
Review literature and establish framework (1996-99)
Create a vision for health care and related policies (1999-2001)
Operationalizing the vision (2001- current)

Six aims for improvement of quality healthcare

Safe care
Effective care
Patient-centered care
Timely care
Efficient care
Equitable care

SAFETY ERRORS
Error: the failure of a planned action to be completed as intended or
the use of a wrong plan to achieve an aim.
Active
committed by people who are in direct contact with the patient

Latent
removed from the practitioner and involving decisions that affect the
organizational policies, procedures, allocation of resources
the inevitable

Organizational system failure

failureindirect failures involving management, organizational culture,
protocols/processes, transfer of knowledge, and external factors

Technical failure
indirect failure of facilities or external resources

SIGNIFICANCE
Nursing Students
Education techniques
Patient- centered thinking

Nursing as a whole

Technological advancements
Policy changes and enforcement
Research
Increased satisfaction
Most importantly: we are providing safe care to our patients

CONCLUSION
Increase in patient safety through increasing the quality of care
Increased safety
decreased adverse events
mortality rates
Investigating causes of adverse events

Impact on nursing profession

Ever-changing
GOAL: achieved

decreased

REFERENCES
http://
www.nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Q
uality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx

Hughes, R. (2008). Patient safety and quality: An evidence-based

handbook for nurses. Rockville, MD: Agency for Healthcare Research
and Quality.
Brusaferro, S., Calligaris, L., Molendini, L., Pietra, L.,& Quattrin, R. (2005).
Medical errors and clinical risk management: State of the art. Acta
Otorhinolaryngol Ital, 25(6), 339346. Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639900/
Google: Crossing the Quality Chasm: A New Health System for the 21st
Century