Errors, Preventable Negative Outcomes, And the Role of the Nurse
Beth Ulrich, EdD, RN, CHE, FAAN, Editor

Remember the first time you made a medication error or didn’t have time to do something the patient needed? If you were like most nurses, the medication error felt like a devastating event, regardless of whether the patient outcome was inconsequential or a major problem and the guilt over the missed care was high. Then, as time passed, perhaps you got a bit complacent about your definition of “on time” and on what you considered a significant or reportable error or omission.

Beatrice Kalisch, in a 2006 study of care on medical-surgical units using focus groups with nurses and unlicensed staff, found that care was routinely missed or delayed, and that such patterns had become accepted. While there were many reasons for the missed care – too few staff, poor use of existing staff, time required for nursing interventions, poor teamwork, ineffective delegation, habit, and denial – the fact remains that relationships have been found in numerous studies between the types of nursing care that were missed and negative (and perhaps preventable) patient outcomes.

Errors – A Big Problem
Errors in health care have become a big problem. The spotlight began to focus more on errors in 1999 with the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, which quantified the number of errors and their resulting consequences, estimating that medical errors were responsible for 48,000 to 98,000 patient deaths each year, making such errors the 8th leading cause of death in the U.S. at the time. In 2003, another IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, highlighted the relationship between nursing work environments and patient safety. Since that time, several other research reports have substantiated the relationship. 

A New Disincentive
The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission have placed ever increasing emphasis on error prevention and patient safety. CMS has instituted accessible comparative data for health care organizations (www.hospitalcompare.hhs.gov), and the Joint Commission delineates National Patient Safety Goals each year for all types of health care facilities. Now, CMS and several major insurance carriers are adding another strategy. Effective October 1, 2008, they will stop paying for preventable errors and “never” events, such as hospital-acquired infections and pressure ulcers, falls, objects left in surgical patients, and air embolisms. It’s pretty hard to argue with their logic – if it shouldn’t happen, they don’t want to pay for it.

While nephrology nurses who work in hospitals will see the direct effects of the new policy between now and October 1, nephrology nurses who work in outpatient dialysis units may not see them for some time. However, it is logical to expect that instituting this policy in hospitals is the forerunner of instituting it in all health care settings. Department of Health and Human Services Secretary Mike Leavitt, in an interview with Modern Healthcare on May 1, 2008, was clear in his desire to eliminate what he terms “quality indifference” (where payment is not related to value) and to move to systems that replace payments for volume with payments that rely on value as the best reward incentive.
    
Opportunities and Challenges for Nurses
This new payment approach presents both opportunities and challenges for nurses. Without a doubt, our role as patient advocates calls on us to do our best to ensure patient safety. A number of items that will not be paid for after October 1 include nurse-sensitive outcomes, either because nursing is responsible for documenting the status at admission or because the amount and quality of nursing care while the patient is in the hospital directly affects the outcome. The interesting question is whether nursing will step up and say, “Yes, we can make a difference here,” and engage in addressing the systemic issues that make the difference in whether a patient has one of the “do not pay” conditions, or whether we will let other people take charge.

The “little” errors and omissions to which we may have become too accustomed or let slide by, in reality, can easily become big problems for our patients, or at the least, such an attitude can create an environment that is too laissez-faire for safe patient care. This is a challenge that deserves our best efforts. Keeping patients safe and unharmed has been a basic tenet of our profession since the profession began. When it comes to patient safety, we need to take the lead.

Beth Ulrich, EdD, RN, FACHE, FAAN
Editor
E-mail: BethUlrich@aol.com