By and large, hospitals are extremely safe places—thanks in large part to nurses, who are responsible for delivering safe, exceptional patient care. Nurses are on the frontlines to prevent safety hazards, and make sure each and every patient receives the best care they need.
However, in the rare instances when something goes wrong in the system, the potential consequences of errors are severe. Investigators at MedStar Health Research Institute and the MedStar National Center for Human Factors in Healthcare are analyzing reports across the industry to identify opportunities to improve patient safety and provide healthier, more supportive environments for nurses and other providers on the frontlines.
This work is in partnership with the Pennsylvania Patient Safety Authority, an independent state agency that receives between 270,000 and 300,000 reports annually from acute care settings on safety hazards and near misses from clinical settings across the state.
This wealth of information allows our collaborative of nurse investigators, other clinicians, and human factors experts to take a long view on important topics like making the hospital a safer place for patients and a better place to work for nurses. We’re focused on two big questions.
- How can we reshape the reporting process and tools so they’re easier to use?
- How can we make systematic changes in facilities, tools, and processes the industry uses to help nurses successfully deliver the highest quality care?
Opportunities to improve EMR and reporting processes.
When staffing is short and patients are many, the task of reporting errors can be especially burdensome. We’ve learned from the data that electronic medical record (EMR) usage can be optimized to benefit patient safety.
The information nurses need to properly administer medications, for instance, could be consolidated to one screen, reducing the chances of error. Reporting processes also can be streamlined in EMRs. Smart user interface design such as dropdown menus instead of open text fields can simplify the task.
Most importantly, administrators have an opportunity to encourage and even incentivize clinicians to anonymously report patient safety hazards without fear of retribution or scrutiny. Some hospitals across the country are building a culture that encourages reporting so that system weaknesses can be quickly identified. This approach is warranted throughout our nation’s healthcare system.
Nurses are often the clinicians who identify and report safety hazards. Optimizing efficiencies in reporting can allow nurses more time to spend in direct patient care, where we know they are most effective.
Small, system-level changes can benefit nurses and patients.
To help solve patient safety and reporting concerns, we must align our healthcare systems to the known capabilities of the humans who staff them.
Pennsylvania PSA data show that misreading medication labels is a contributing factor in safety hazards. A major culprit? Poor lighting in areas where nurses work most. Throughout the team’s prior research, we’ve analyzed best practices for adequate lighting in medication rooms, ensuring our nurses have the benefit of proper working conditions.
Similarly, we’ve previously examined the design of patient wards. Can nurses see the call lights outside every room? How many steps do clinicians take each day, and will moving resources closer reduce fatigue? Relatively simple measures such as designing spaces with staff workflow in mind can make a big difference.
Reducing safety hazards is ongoing, and building a culture of safety is an incremental process.
There’s more work to do.
As we enter our fourth year of collaborating with Pennsylvania PSA, we are also working to help patients and families be advocates involved in each step of their care, further reducing the chance of safety hazards.
For more information about this work, explore the National Center for Human Factors in Healthcare and the Agency for Healthcare Research and Quality. Both are excellent resources for understanding safety hazards and preparing to advocate for yourself and your family’s healthcare.
The vast majority of hospital visits go according to plan, and patients leave our care on the road to recovery. That’s an impressive track record of very complicated systems operating properly, especially in the face of challenging working conditions for many nurses and other clinicians. We’re working to make that success rate even better by recommending incremental improvements that can be implemented in hospitals nationwide.
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