Editorial

QUALITY OF CARE, HEALTH SYSTEM ERRORS,AND NURSES

Nurses have a major responsibility for the quality of care

provided to people.

Why? Because nurses comprise the largest component

of the healthcare workforce and are heavily involved with

the professional management and provision of care.

Nurses are accountable for much of the health care

provided in many countries and for the design of health

systems through which care is delivered, quality is

assured, and errors are avoided.

The US Institute of Medicine (IOM) de®nes quality as

`The degree to which health services for individuals and

populations increase the likelihood of desired health care

outcomes and are consistent with current knowledge.'

Four types of quality-related problems compromise the

quality of care: avoidable errors, underuse of services,

overuse of services, and practice variance.

In the United States it is estimated that at least 98 000

deaths occur each year because of one or more types of

health system errors. Several studies suggest that these

errors, of all types, are the eighth leading cause of death in

the United States.

Last fall, the Institute of Medicine released a report on

errors entitled, To Err is Human, which got everyone's

attention. In the report, patient safety is de®ned as freedom

from accidental injury, and error as the failure of a planned

action to be completed as intended or the use of a wrong

plan to achieve an aim. The report concluded that errors are

widespread and pose a signi®cant threat to patient safety

and that many things we currently do in health systems to

prevent errors are not particularly effective.

One of the things we do, which is not effective, is attach

blame to individuals for the errors committed. And this is

the crux of the problem! The world's foremost authority

on errors, Lucien Leape, says, `Stop the blame game!

Think systems! Ask, `What happened?' not `Who did it?'

Throughout his years of study of errors in health care he

®nds that everyone makes errors every day. Some of these

errors are the result of misconduct. But very few. The

problem, rather, is system design and function.

Health systems are very complex. Hospitals, for

example are among the most complex organizations on

earth. And many hospitals throughout the world lack

adequate coordination and mechanisms to ensure patient

safety. Consider, for example, the incomplete information

most practitioners have about people's medication and

previous illnesses. Yet despite the evidence we now have

that systems fail, managers and other authorities continue

to blame the person who gives the wrong medication, or

the one who hangs the wrong IV.

Expert evidence and the efforts of thoughtful

researchers shows us that instead of blaming nurses and

doctors, instead of pointing the ®nger and alleging

misconduct, we must understand, to a much greater

degree than we do presently, the basics of health systems

so that we can more easily identify then eliminate prob-

lems with organization design and maintenance.

Dr Leape suggests that we design work with the human

factor in mind and construct an organization that avoids

reliance on a person's memory; that simpli®es even the

most complex tasks; that we standardize; that we create

forcing functions by designing so that it is dif®cult, even

impossible to do the wrong thing; and that we use

protocols wisely and with logic.

Nurses work long hours. Their workload is often exces-

sive. They must often make decisions with incomplete

information and spotty feedback. There is hurry, fatigue,

anxiety, and fear. There are system design problems and

defects that trigger unsafe acts and the resulting errors and

accidents.

Think systems! We are doing better at this level of

thinking in nursing but we have a long way to go!

The building blocks and design logic of organizations

must be part of every nurse's education and training. Nurse

managers must be trained in the basics of system func-

tioning and maintenance. Standards, procedures, rules with

an emphasis on making it easy, not complex are required.

Automation can be greatly improved. Teamwork can be

reformulated so that doctors and nurses and pharmacists

truly work together not just side by side. Best practices can

be identi®ed and implemented. And traditional roles

should be rethought Ð to reduce all types of errors, to

improve the quality of care, to lessen human suffering.

Beverly Henry

Editor for the Americas

Ó 2000 Blackwell Science Ltd 773

Journal of Advanced Nursing, 2000, 32(4), 773±775