editorial
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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