Creating Safe Environments for Patient Care: Where Are We Today?

Abstract

Five years have passed since the Institute of Medicine (IOM) report, To Err is Human, provided substantive insights about the magnitude of the patient safety problem in the U.S. health care system (Kohn, Corrigan, & Donaldson, 2000). Although the focus of that seminal report was on the United States, there is evidence that errors and safety in health care delivery are a global issue. In fact, the probability of adverse events is likely much higher in developing countries due to the variable quality of infrastructure and equipment and the lack of adequate financing for essential health care services. The focus also has been primarily on risks in hospitals but it is acknowledged that other settings, such as long-term care and community settings, are probably producing adverse events as well; they just have not been documented as extensively (World Health Professions Alliance, 2002). A number of reports are now appearing that assess progress made to date in improving health care delivery. It is important to note that, after 5 years of focused efforts to improve safety in health care, the public does not feel safer. High levels of dissatisfaction with health care continue to be reported and large numbers of patients and their families continue to be concerned about safety (Altman, Clancy, & Blendon, 2004). While many promising efforts have been launched, the task is far from complete. A report card on the progress to date assesses progress as insufficient over the past 5 years. Some progress has been made in the area of regulation and information technology but other areas, such as workforce training and accountability, are still in need of substantial effort. Many of the challenges relate to issues in the practice environment, such as the difficulties faced when promoting a no-blame culture. Another critical issue is the lack of mental models about what is needed to create and maintain safe care environments (Wachter, 2004). Knowledge development needs are extant in this area. Theory and model development are essential in explaining not only why empirical relationships occur but also predicting conditions when they will occur in the future. Much of the work around nurse staffing presents a relevant example. A growing body of research relating nurse staffing to adverse outcomes is available. In fact, some might characterize it as confirming the obvious. Generally, the research does not provide a clear understanding of why this occurs and what interventions might be proposed to address the multidimensional issues. The work to date has not resulted in the knowledge development and theoretical work that is so important. Theory development is needed to identify the major constructs of interest, how they relate to each other, and the contextual factors that mediate or moderate the proposed relationships (Mark, Hughes, & Jones, 2004). Until this type of theory development is done, studies will continue to document that there is a relationship between staffing and adverse patient outcomes but will not provide much insight about effective interventions to change those outcomes. …