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University of South Florida

College of Nursing
Adison Pusateri
 PATIENT SAFETY & QUALITY CARE: A
MOVEMENT TOWARDS A BETTER
HEALTHCARE SYSTEM
Introduction:
What is the patient safety and quality
care movement and why is it needed?
Types of safety errors
Institute of Medicine aims for
improvement
Approach to improve safety in
healthcare
Significance to the profession of nursing
Significance to a student of nursing

2 Patient Safety & Quality Care: A Movement Towards a Better

 PATIENT SAFETY & QUALITY CARE
MOVEMENT
What is it?
Enacted in 2005 to address the issue of
patient safety
Goal to encourage healthcare
professionals to report issues with
patient safety by providing
Why is it needed?
confidentiality when reporting to improve
data and patient safety1
A 2016 study conducted by Johns Hopkins
found:
250,000+ Americans die each year from
medical errors2
This is up from the 98,000 annual deaths
reported in the IOMs 1999 report, To Err is
Human3
Medical error is the third leading cause of
death in the United States2

3 Patient Safety & Quality Care: A Movement Towards a Better

 PATIENT SAFETY & QUALITY CARE----
Types of safety
errors:
Root causes of harm as defined by the National
Quality Forum4

Latent failure- removed from practitioner,

involves organizational policies, procedures,
and resources
Active failure- direct contact with patient
Organizational system failure- indirect,
involves management, organizational culture,
protocol, communication, and external factors
Technical failure- indirect failure of facilities
or external resources

4 Patient Safety & Quality Care: A Movement Towards a Better

 INSTITUTE OF MEDICINE----
6 Specific aims for improvement:
According to the IOMs 2001 report, Crossing the
Quality Chasm: A New Health System for the 21st
Century, there are 6 specific areas in which healthcare
needs to be improved upon5:

1. Safety
2. Efficiency
3. Patient-centeredness
4. Timeliness
5. Effectiveness
6. Equitability

5 Patient Safety & Quality Care: A Movement Towards a Better

 INSTITUTE OF MEDICINE---
Approach for improvement:
The IOMs 1999 report, To Err is Human, establishes a
four-tiered approach to improve Americas healthcare
system safety record3:

1. Establishing a national focus to enhance the

knowledge base about safety
2. Identifying and learning from errors by developing a
mandatory reporting system and encouraging
healthcare organizations to participate in voluntary
reporting systems
3. Raising performance standards and expectations for
improvements in safety through the actions of
healthcare groups and organizations
4. Implementing safety systems in healthcare
organizations to ensure safe practices at the delivery
level

6 Patient Safety & Quality Care: A Movement Towards a Better

 PATIENT SAFETY & QUALITY CARE---
Significance to the nursing
profession:
The most critical contribution
of nursing to patient safety, in
any setting, is the ability to
coordinate and integrate the
multiple aspects of quality
within the care directly
provided by nursing, and
across the care delivered by
others in the setting.4

7 Patient Safety & Quality Care: A Movement Towards a Better

 PATIENT SAFETY & QUALITY CARE---
Significance to a nursing student:

Principles to take away:

Safety
Evidence-based practice
Patient-centered care
Importance of nursing role

8 Patient Safety & Quality Care: A Movement Towards a Better

 WORKS CITED
1. Patient safety and quality improvement act of 2005. December
2012. Agency for Healthcare Research and Quality, Rockville,
MD. Retrieved from:
https://archive.ahrq.gov/news/newsroom/press-releases/2008/ps
oact.html
2. Hughes, R.G. (Ed.). (2008). Patient Safety and Quality: An
Evidence-Based Handbook for Nurses. Rockville, MD: Agency for
Healthcare Research and Quality.
3. Frieden, T. (2016, May 1). Re: Methodology used for collecting
national health statistics [Electronic mailing list message].
Retrieved from
https://www.documentcloud.org/documents/2822345-Hopkins-CD
C-letter.html
4. Kohn, L.T., Corrigan, J., & Donaldson, M.S. (1999). To err is
human: building a safer health system. Washington, D.C.:
National Academy Press
5. Baker, A. (2001). Crossing the quality chasm: A new health
system for the 21st century. BMJ, 323(7322), 1192. doi:
10.1136/bmj.323.7322.1192

9 Patient Safety & Quality Care: A Movement Towards a Better