PATIENT SAFETY AND

QUALITY CARE
MOVEMENT Paige Guers
University of South Florida
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Introduction
1999 To Err Is Human: Building a
Safer Health System
Reported between 44,000 and
98,000 people dying as a result of
preventable errors1
Preventable medical errors
contributed to more deaths than
motor vehicle accidents, breast
cancer, or AIDS1
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Patient Safety & Quality Care Movement
Quality: The degree to which health services for individuals
and populations increase the likelihood of desired health
outcomes and are consistent with current professional
knowledge2
Safety: The prevention of harm to patients2
Prevent errors
Learn from errors that do occur
Build a culture of safety that involves healthcare
professionals, organizations, and patients

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IOM Concepts
Crossing the Chasm: A New Health System for the 21st
Century
Six Aims of Improvement:
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable3,4

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Types of Safety Errors
Safety Error = The failure of a planned
action to be completed as intended or
the use of a wrong plan to achieve
aim1
Ex. Adverse drug events, improper
infusions, surgical injuries and wrong site
surgery, suicides, restraint related
injuries or death, falls, burns, pressure
ulcers, mistaken patient identities1, etc.

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 Types of
Safety Errors
Type
Communication
Patient
management
Clinical
performance2

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Types of Safety Errors
Latent failure = organizational policies, procedures, and
allocation of resources
Active failure = direct contact with the patient
Organizational system failure = indirect management
and external factors
Technical failure = indirect failure of facilities or external
resources2

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Significance of Patient Safety &
Quality Care Movement to Nurses
Nursing is the key to improving quality
Nurses are advocates for safe care
Florence Nightingale
Reduced mortality rates by improving
organization and hygienic practices2

Evidence based-practice
Strong nurse-patient relationships

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Significance of Patient Safety &
Quality Care Movement to Nurses
The cost of human lives
The cost of additional care
Loss of trust in the healthcare system
Diminished patient satisfaction
Longer hospital stays
Loss of moral and worker productivity
Lower levels of population health1
Between $17 billion and $29 billion1

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Significance of Patient
Safety & Quality Care
Movement to Students
Focused attention on the
prevention of medical error
Knowledge is power
Critical thinking
The Quality and Safety
Education for Nurses (QSEN)
initiative
Knowledge, skills, and attitude
to improve healthcare6
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Conclusion
NO BLAME
Nurses are a critical part of providing
patient safety
No patient should be harmed by the health
care system again

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References
1. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human: Building a safer health system.
Washington, D.C: National Academy Press.
2. Mitchell, P.H. (2008). Defining patient safety and quality care. In R.G. Hughes (Ed.), Patient safety and
quality: An evidence-based handbook for nurses (pp. 1-11-6). Rockville, MD: Agency for Healthcare
Research and Quality (AHRQ) Publication No. 08-0043.
3. Ballard, K. A. (2003). Patient safety: A shared responsibility. Online Journal Of Issues In Nursing, 8(3), 105-
118.
4. The National Academies of Sciences. (2013). Crossing the quality chasm: The IOM health care quality
initiative. Retrieved from
http://www.nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-
Chasm-The-IOM-Health-Care-Quality-Initiative.aspx
5. Wachter, R., & Pronovost, P. (2009). Balancing "No Blame" with accountability in patient safety. New
England Journal of Medicine, 361(14), 14011406.
6. Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is
systems thinking. Online Journal of Issues In Nursing, 18(3), 1-12. doi:10.3912OJIN.Vol18No03Man01

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