Patient Safety Awareness Week: Reducing Errors and Improving Safety

Maura Cash, RN, BSN, CASC

Vice President of Clinical Strategies

Patient Safety Awareness Week (March 13-19) is recognized annually by the  Institute for Healthcare Improvement (IHI) to spotlight safety concerns. This week is an excellent opportunity to review the history of patient safety, common causes of safety issues, and most importantly, what we can do to improve patient safety and reduce errors.

Safe surgical care while producing quality outcomes has always been the goal of Ambulatory Surgery Centers. Finding solutions is the only path to lessening errors and improving safety when it comes down to it. Let’s dive in.

The History of Patient Safety

Studies have shown a staggering number of patients harmed by preventable medical errors. As many as 400,000 deaths occur in the United States each year due to mistakes or preventable harm. That number skyrockets if you include cases of harm that do not necessarily result in death. Errors can cause a long-term impact on the patient’s physical health, emotional health, financial well-being, or family relationships. Many of these errors occur in the ASC industry and hospitals and clinics. These errors include systems failures, human factors, complicated technologies, powerful drugs, increased case volume, staffing shortages, and cost-cutting measures, to name a few. These errors can result in billions of dollars in excess health care costs nationwide each year.

The Patient Safety and Quality Improvement Act of 2005 (Public Law 109-41), signed into law on July 29, 2005, was enacted in response to a growing concern about patient safety in the United States. According to the Institute of Medicine’s 1999 report, To Err Is Human: Building a Safer Health System, between 44,000 and 98,000 Americans die annually due to preventable medical errors. The report urged health care institutions to break the silence surrounding such errors and implement changes that would promote a culture of safety. The Act’s goal was to improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients. Preventing harm in health care settings, including ASCs, is a public health concern. Everyone interacts with the health care system, and ASC providers have a role in advancing safe health care.

IHI wants to encourage clinicians to use the week to learn new standards and practices, especially in light of COVID-19, and educate patients and their caregivers on how to protect themselves across the healthcare spectrum. It is not enough to put a spotlight on safety concerns. Finding solutions is the only path to lessening errors and improving safety.

What are Common Causes of Safety Issues?

• Fatigue – working while tired and rundown can make it harder to think and concentrate, leading to mistakes.
• User Error – this has become more of an issue now that much documentation has shifted to Electronic Medical Records (EMR), and staffing shortages have led to agency staffing. Errors can occur when clinicians are unfamiliar with a system and don’t receive proper training.
• Inexperience – everyone has to start somewhere, but when new staff fails to follow policies/procedures, it can lead to a preventable error.
• Human Error – regardless of protocols and standards of care, when those guidelines and regulations aren’t followed, it can lead to patient harm.

What can we do?

 Own your fatigue.

• Ensure your attention to safety never wavers and notice when you feel distracted. If you think you are too tired to perform your assignment effectively, you MUST speak up. Whether you need a break, help, or a day off – you have to ask for it.
• Take care of yourself by getting enough sleep, staying hydrated, eating nutritious foods, and managing stress.
• Practice excellent personal hygiene and encourage it in colleagues, patients, and caregivers. Hand washing protects everyone.

Provide a safe environment.

• If you are working with new staff, whether they are temporary or have just joined your center, buddy up. Give each new worker a skilled coworker where they can ask for help. We need to provide a safe environment for our clinicians to reduce the potential patient safety minefield they face every day.
• If you notice a process that is creating a safety concern or has the potential to, address it with your supervisor. Propose a strategy around high-risk activities to become a standard care plan in your organization.

Improve your knowledge base.

• Ask for continual professional development opportunities around patient safety.
• Get involved in patient and healthcare worker safety in local and national AORN and ANA organizations and your government representatives. A letter to a representative or supporting a professional organization that works for these issues can make a difference.

Being an advocate for the patient is part of your focus every day. It may be their first surgical experience, but it is not yours. A calm, reassuring demeanor and dedication to their positive outcome will help ensure fewer incidents of patient harm. Educate all who will listen. Talk about patient safety to peers, colleagues, patients, family members, and other caregivers. Raise awareness with continual discussion and make improvements whenever possible. The safety of your patients is in your hands.