Nursing: Patient Safety Concept Analysis

Introduction

The concept of patient safety has a profound impact on the care continuum. Patient safety can determine if a patient lives or dies. Medical errors that result either from commission or omission have been known to cause premature deaths or severe health conditions that could easily have been avoided. Apart from the loss of lives or worsening of the quality of life, medical errors increase the total costs incurred by patients and their families as well as healthcare organizations. A patient who suffers due to medical errors may lose his productive capability and hence his ability to earn a living for the family. Medical errors increase the expenditures of a family due to increased hospital visits, more costly treatments, and longer hospital stays. Kohn, Corrigan, and Donaldson (2000) in the Institute of Medicine’s report To Err are Human to argue that, “medical errors have been estimated to result in total costs of between $17 billion and $29 billion per year in hospitals nationwide,” (p. 40). Healthcare organizations and their employees also suffer as a result of medical errors. For one, they lose the trust patients and their families once had in them. In addition, healthcare practitioners may suffer from lower morale and job satisfaction levels that may result from feelings of guilt and the knowledge that life could have been saved if only they were more attentive and less negligent. In cases where patients and their families choose to file a lawsuit, healthcare organizations lose money in form of legal fees as well as a negative public image.

Patient safety is not only significant in nursing practice but also nursing research, nursing education, and nursing leadership and management. Leadership plays an important role in patient safety. Senior leaders have both the duty and the power to make patient safety a premeditated priority in the healthcare organization. If this is to happen, the leadership must be attentive to the concept. First and foremost, the leaders should incorporate patient safety as one of the key objectives of the organization. Making the case in favor of patient safety can also be used as a strategy by the leaders (Larson, 2002). There is also a need to focus on the competency development of quality and safety, capacity building in nursing education programs, the faculty and nursing shortages, and implementation of new methods of being at par with an ever-evolving health care environment. One of the key purposes of putting in place quality and safety competencies in nursing education is to narrow the gap between the theory and practice of nursing. This can be achieved through the training and development of education programs that emphasize patient safety. Patient safety, therefore, has a significant impact on the entire healthcare system.

The significance of patient safety to nursing is the basis of this paper. This paper will provide critical analysis of the concept of patient safety as it applies to nursing. The concept analysis will be achieved through a critical analysis of relevant literature as well as the application of the concept analysis model proposed by Walker & Avant (2005) which is made up of eight stages: selection of a concept, statement of the aim of the analysis, introduction to all the uses of the concept, identification of the defining attributes, identification of a model, borderline, related, contrary, invented and illegitimate case, extraction of antecedents and consequences and provision of empirical references.

Uses of the Concept

The concept of safety is used in almost all fields of practice. Safety is indeed a major concern to everyone not only in healthcare organizations. For instance, safety in the home is ensured in several ways. Families with very young children have to ensure that their children are safe from self-imposed harm by for instance keeping all hazardous items such as nylon papers or medicine out of the reach of the children. Homes also ensure safety by keeping surfaces dry to avoid falls that result from wet surfaces. The concept of safety is also widely applied in the management of industries, for instance, the construction industry. The management of such industries has to ensure that its constructors are well protected by providing them with protective gear such as gloves and helmets. Besides the workers, the management has to ensure that passersby and the eventual occupants of the building are safe from the collapse of the building. This necessitates complying with the rules and regulations of construction.

Besides the use of the concept in different fields, the concept is also used in the English language.

Various dictionaries, encyclopedias, and thesaurus have defined the concept in several ways. The term patient is defined by the Merriam-Webster Online Dictionary as: “an individual awaiting or under medical care and treatment; the recipient of any of various personal services; or one that is acted upon” (p. 1). The Medical Dictionary on the other hand defines a patient as a person who is receiving health care. The dictionary further argues that the definition of this term is diverse due to a lack of consensus among scholars. It further states that a patient may have already received medical/health care, maybe waiting for such care, or maybe undergoing such care. The use of this term is dated back to the 14th century and originates from the Latin word pater which means suffering. The term safety on the other hand is defined by the Free Online Dictionary as: “the condition of being safe or freedom from danger, risk, or injury” (p. 1). The definition of the term safety thus implies that there has to be the presence or absence of certain elements, things, or situations for the condition of safety to occur. Taken together, the concept of patient safety, therefore, implies a situation in which recipients of medical or health care are protected from harm or injuries that may arise in the course of receiving the care and that may be caused directly or indirectly by the providers of the medical/health care. Because the meaning of the patient safety concept implies a situation, the health care organizations need to put in place certain measures, structures, or processes to ensure that patient safety is upheld.

Review of Literature

The Search Process

Three different databases were used to identify the research articles that have focused on patient safety. Using patient safety as the keywords and limiting the results to peer-reviewed articles only, 67120 results were found in the EBSCOHOST database. This figure was further reduced to 43,745 after limiting the results to articles published between 2005 and 2010. In the PROQUEST database, 4890 results were found in the first stage which was then reduced to 4022 after limiting the results to articles published between 2005 and 2010. In the CINAHL database, 15184 results were found in the first round and 10304 results were found in the second round. Eventually, only 11 articles were selected for this study. The choice of the articles was based on the content of the abstract of the articles, the title of the articles, their date of publication, and their relevance to this paper. It is however interesting to note that although the first round of results was not limited by the dateline, the majority of the articles (almost 70 percent) were published between 2005 and 2010. This illustrates the fact that the concept of patient safety attracted the greatest attention only in the recent past after the publication of the Institute of Medicine’s report To Err is Human: Building a Safer Health System.

Literature Review

Patient Safety as a Hazard-Free Concept

Goodman (2003) argues that the health care industry is similar to other high-hazard industries such as the aviation and petrochemical industries. The hazardous nature of any industry is determined by its end product which in health care is the patient outcome. The author further argues that organizations that are considered as safe apply organization-wide, all-inclusive, persistent, and transparent safety management strategies. Unfortunately, the same cannot be said of the health care industry because of the challenges it faces in trying to adopt a safety model that is based on other high-hazard industries. Some of these challenges include the lack of understanding of the concept of safety management as a science and the failure by health care organizations to employ safety management experts. Patient safety in health care organizations is illustrated by the occurrences and frequencies of errors, accidents, and adverse incidents that could otherwise have been avoided.

Patient Safety as Lack of Use-Related Errors and Hazards

This concept is almost similar to the earlier concept. The only difference is that while the former focuses on errors that are caused directly by healthcare providers, the latter focuses on errors that result from dysfunctional medical devices. Gruchmann (2005) argues that the design and manufacture of many medical devices are not always based on the needs of the users or the working conditions of the organizations. Due to stiff competition manufacturers try to distinguish themselves by designing and producing complex devices which are a challenge for the users. The lack of information about the working conditions of the organizations leads the manufacturers to produce devices that were modeled on their mental processes and assumptions. Such limitations are founded on the assumption that the users could find their way around the devices and make them work. To enhance patient safety, healthcare organizations need to implement usability engineering methods to minimize use-related errors, risks, and hazards. Furthermore, the devices should be developed through active interaction between the developers and the users, for instance, by observing the devices at work and by interviewing the users about the challenges or benefits of using the devices. On the other hand, the users (particularly nurses) should be encouraged to report any problems they have with the medical devices rather than perceiving the problems as incompetence (Gruchmann, 2005).

Patient Safety as a Nurse-Patient-Family Partnership

Ponte, Connor, DeMarco, and Price (2004) argue that patient safety can only be realized if there are mutual and beneficial relationships among the health care providers, patients, and their families. This is because such relationships have a great impact on the planning, delivery, and assessment of health care. The authors argue that the failure of healthcare organizations to maintain patient safety has largely been attributed to the organization of the healthcare around the needs of the healthcare providers rather than on the needs of the patients and their families. However, this approach would require significant restructuring of most organizations from their long-existing paradigm to the new paradigm. The significance of patient-focused care lies in its ability to enhance the team performance of all the partners of the organization. Collaborative teams in turn are highly able to minimize the occurrence or frequency of errors even in settings that require multidisciplinary teams such as the operating room. Ponte et al. (2004) argue that “efforts to develop safe care practices must all be based on one common element: building consensus among multidisciplinary, high-performing teams in which communication, collaboration, transparency, and joint decision making occur,” (p. 213). The importance of healthy patient-family-professionals partnership is also highlighted by AHC Media (2007).

Taxonomy of Patient Safety

Ralston and Larson (2005) assert that “patient safety is freedom from accidental injury,” (p. 61). They argue that this definition implies that the concept is easily managed and understood. However, given the complexity of healthcare organizations, patient safety may become an unachievable goal. The concept continues to emerge in a complicated system that is made up of persons, processes, structures, clients, and caregivers. As a result, any healthcare organization that wants to provide safer care needs to understand the dynamic nature of the concept. Patient safety, according to Ralston and Larson (2005), has several dimensions which include: error, adverse event, preventable adverse event, and a near miss. An adverse event is an incident or omission that occurs during the provision of healthcare and that leads to physical, emotional, or psychological harm. A preventable adverse event is an adverse event that could be avoided if proper procedures had been followed. An error on the other hand is a commission or omission deed that raises the probability of an adverse event based on present accessible information. A near miss is an incident in which an event or omission occurs but does not develop further and thus potential harm to a patient is prevented. Adverse events and near misses are the most common patient outcomes. However, adverse events are evidence of grave weaknesses and limitations inherent in the organization. In other words, they are the tip of the iceberg of the organization’s incompetence.

Defining Attributes

Defining attributes refer to the core elements of the concept, that is, the elements that first come to the mind of people when thinking about the concept (Walker & Avant, 2005). From the literature review above, the defining attributes of patient safety include the absence of errors, adverse events, near misses, and negligence on the part of the healthcare provider. Patient safety is also attributed to open communication and interaction among healthcare providers, patients, and families. In addition, it is attributed to safe, efficient, and easy-to-use medical devices. Patient safety, therefore, entails a shift by the organization from provider-centered care towards patient-centered care that addresses the needs of the patient.

Definition of Patient Safety

Based on the literature review and the defining attributes, patient safety can thus be defined as a situation in which the errors committed against patients, as well as the near misses and adverse effects of patients, are eliminated through an open relationship between the patient and the healthcare professionals. Patient safety is an ongoing process of change that takes into account and adapts to the dynamic and complex nature of healthcare organizations for the good of the patient. It is a new model of provision of healthcare services to patients in which the needs of the patients are placed above the needs of the other parties involved.

Cases

Model Case

A model case contains all the defining attributes of the concept (Walker & Avant, 2005). A model case example for the concept of patient safety is illustrated below:

Miss. Y started experiencing joint pains, fever, and chills on a Monday evening. On Tuesday morning, she began suffering from diarrhea while the joint aches worsened. She was convinced that she was suffering from malaria but decided to visit her physician. Miss. Y and her physician engaged in a lengthy conversation. The physician wanted to know when her illness began and her activities the day before she started experiencing the symptoms. Miss. Y described in detail that she had attended a friend’s party the day before her illness began where she ate and drank merrily. Not wanting to make non-factual judgments, the physician sent her for laboratory tests. The tests showed that Miss. Y had food poisoning and not malaria. The lab tests enabled the physician to prescribe the correct drugs and Miss. Y recovered from her illness within two days.

The case above contains all the defining attributes of patient safety. There was an open relationship between the patient and the physician in which both parties comfortably communicated with each other about the issues at hand. This in turn helped to avoid adverse events, near misses, and medical errors that could result from misdiagnosis or inaccurate prescription of drugs.

Borderline Case

A borderline case is almost similar to a model case but it lacks one of the defining attributes of the concept (Walker & Avant, 2005). An example of a borderline case is illustrated below:

Mr. P suffers from chronic arthritis but is also emotionally unstable. During one of his visits to his doctor, he becomes hysterical and threatens all those present in the waiting room. He also threatened to kill himself to end the pain. The physician advice his family that needs to be admitted for a close watch. The nurse is also advised to physically constrain him to his bed to protect others and himself from any harm. This measure is also communicated to the patient and his family and they all agree. Unfortunately, this event takes place on a Friday evening. The nurse in charge of him does not report on Saturday because it is her day off. As a result, Mr. P remains constrained the entire weekend which in turn causes injuries on his arms and legs where the constraint was applied.

This case has the attributes of open relationship among the patient, his family, and the physician, absence of errors, and absence of near misses which are all defining attributes of patient safety. However, the absence of adverse events is lacking in the case. Mr. P indeed suffers an adverse event in the form of physical injuries.

Related Case

A related case is similar to the concept. It is used to further aid the comprehension of the concept (Walker & Avant, 2005). An example is illustrated below which illustrates the concept of security:

During an interview with the Ministry of Health officials, my neighbor stated that she and her family members have always attended St. Johns Hospital, Mississippi. She stated that every time she visits the hospital, she always feels safe and certain that she will recover well.

Although the neighbor does not state the reasons for her sentiments about the hospital, it seems that she and her family have never suffered adverse events, errors, or near misses. The statement also implies that the patient has a good and open relationship with the hospital’s medical professionals. This is probably why she feels secure in their hands.

Contrary Case

A contrary case does not represent the concept in any way (Walker & Avant, 2005). An example of a contrary case is illustrated below:

The management of one of the local hospitals was once known for its insistence that the hospital offers safe and high-quality health care. While covering a news piece on healthcare services in the area, one of the local television stations decided to pay an impromptu visit to that particular hospital. The journalists discovered that the hospital lacked adequate facilities such as beds which forced patients to share beds thus increasing the rate of infectious diseases in the hospital. It was also discovered that the healthcare professionals did not spend adequate time with the patients and therefore there was no open relationship between them. As a result, many cases of medical errors, adverse events, and near misses were reported.

The case above does not represent patient safety at all.

Invented Case

An invented case is a case that seems far-fetched and “outside the box.” However, invented cases contain all the defining attributes of the concept (Walker & Avant, 2005). An example of an invented case is illustrated below:

Mr. X’s niece had her arm amputated following a misdiagnosis of an infection. Since then, Mr. X takes extreme measures to ensure that he does not suffer a similar occurrence. Mr. X always attends different hospitals for the same illness to ensure that the initial physician did not make a wrong diagnosis or prescribe the wrong drugs. Only when the results are the same does he proceed with the treatment. In addition, he always insists on having lengthy discussions with his physician and nurses just to make sure that he is not misunderstood and that he does not misunderstand his caregivers. He also carries a tape recorder to record his conversations with his caregivers to understand his conditions and follow the drug prescriptions to the letter. He argues that such measures help him feel safe because he has never experienced any errors, near misses, or adverse events. In addition, his lengthy discussions help develop an open relationship with his healthcare/medical providers.

This case has all the attributes of patient safety: open communication and absence of errors, adverse events, and near misses. However, the case seems far-fetched.

Illegitimate Case

An illegitimate case is one in which the concept has been inaccurately used (Walker & Avant, 2005). An example of an illegitimate case is illustrated below:

Some nurses believe that trial and error particularly regarding the use of medical devices would enhance patient safety.

This scenario does not accurately represent patient safety because trial and error increase the rate of medical errors, adverse events, and near misses. The approach also hinders the development of an open relationship between the patients and healthcare professionals.

Antecedents and Consequences

Antecedents refer to the building blocks of the concept. That is, they are the elements that have to be present for the concept to be used (Walker & Avant, 2005). The antecedents of patient safety include:

  • Patient: for the patient safety concept to be in place there has to be a patient
  • Absence of medical errors: for patient safety to exist there ought to be a lack of medical errors by the healthcare providers. Some medical errors include wrongful diagnosis of illnesses and inaccurate prescription of drugs.
  • Absence of adverse events: patient safety is applicable if there are no adverse effects that result from medical and healthcare. If a patient suffers from premature death or becomes physically, mentally, or psychologically incapacitated following a medical procedure, then it implies that the concept of patient safety was not applied.
  • Absence of near misses: patient safety is applicable if the organization minimizes the occurrences of near misses as much as possible.
  • Open communication: patient safety can only be realized if there is open communication between the healthcare providers, patients, and the patients’ families. Open communication helps to reduce the occurrences of errors and adverse events in several ways. For instance, open communication between a patient and a physician can help to diagnose an illness accurately because the physician will have adequate knowledge about the symptoms the patient has, their occurrence, and frequency. Open communication between the three parties can also help families to accurately follow the doctor’s prescription and dosage and thus avoid cases of drug overdose which can be blamed on the ignorance of either the patient or his/her family.
  • Consequences of the concept refer to the outcomes of patient safety. If patient safety is upheld in healthcare organizations, the consequences are:
  • Shorter hospital stay: patients would spend lesser time in hospitals because the absence of errors and adverse events would mean that patients do not suffer from additional injuries inflicted on them during the care process
  • Reduced household expenditures: patients and their families would spend less due to shorter hospital stays and fewer hospital visits
  • Increased productivity of patients: patient safety would increase patients’ productivity because of the absence of adverse events and errors that can make them incapacitated
  • More lives would be saved if healthcare organizations apply the concept of patient safety seriously
  • Reduced organizational expenditures: patient safety can significantly reduce the amount of money healthcare organizations lose in lawsuits due to negligence
  • Increased job satisfaction for healthcare professionals due to increased trust from the patients and their families

Empirical Referents

Empirical referents refer to the means through which the concept can be measured (Walker & Avant, 2005). They help to address the question: How safe are patients in healthcare organizations? The measurement of patient safety cannot be measured directly. However, the extent of patient safety can be measured using the defining attributes discussed earlier namely: errors, adverse events, near misses, the usability of medical devices, and the nature of communication between patients, families, and healthcare providers.

Errors

Patient safety can be measured by the frequency and type of medical errors that occur in a healthcare organization. For instance, if a hospital uses physical constraints on some of its patients, patient safety can be gauged by the frequency with which the patients get injuries related to the constraints. The frequency with which patients’ illnesses are misdiagnosed and inaccurate prescription of drugs are also good measurements of patient safety.

Adverse events

Patient safety can also be measured by the frequency with which patients die or suffer from additional physical/mental/psychological harm in the process of receiving. Such adverse events imply that something went wrong somewhere either because the healthcare professionals were ignorant of the patient’s condition or merely because the proper protocols were not followed.

Near misses

The frequency with which adverse events almost happen but are avoided is also a good indicator of patient safety.

Usability of devices

The ease with which healthcare professionals can use medical devices is a good measurement of patient safety. This is because the devices which are difficult to operate have high probabilities of causing harm and injuries to patients in the course of their use.

The nature of communication

The nature of interpersonal communication in a healthcare organization is a good measure of patient safety. Patients are safer in open communication settings because issues can easily be clarified and doubts can be discussed which in turn lead to sound decision making. It is important to note that there is a gap in the literature concerning standardized instruments that can be used to measure patient safety. The reason for the gap may be because patient safety is a relatively new concept in the healthcare industry. Hence such measurement is limited to the defining attributes which can be done either qualitatively, quantitatively, or both. The literature gap presents an abundance of opportunities for the creation of standardized instruments that can measure the concept of patient safety.

Summary and Conclusion

The concept of patient safety has become ingrained in the mission and objectives of most healthcare organizations. Although it has always been an issue since time immemorial, the concept received the attention it deserves after the Institute of Medicine published a report on the extent and degree of patient safety. In the report, the extent of injuries, the frequency of deaths and other adverse events as well as the high costs incurred both by patients and healthcare organizations as a result of lack of patient safety were highlighted. It is because of this report that many scholarly articles have been published since 2000 that focus on patient safety.

The concept analysis presented in this paper has shown that patient safety has several defining attributes which include: absence of errors, adverse events, and near misses as well as open communication. Indeed, when one thinks about patient safety, these elements come to mind almost immediately. Errors and near misses often occur due to the negligence of healthcare professionals or even the patients. Adverse events occur mainly because the right procedure was not followed or adequate information was not given by the patient. To avoid all these incidents, open communication among healthcare professionals, patients, and patients’ families is of paramount significance.

Reference List

AHC Media. (2007). Strategies for improving safety through patient and family involvement in care. Patient Education Management, 14(3), 25-36.

Free Online Dictionary. (2010). Safety. Web.

Goodman, G. (2003). A fragmented patient safety concept: The structure and culture of safety management in healthcare. Research and Perspectives on Healthcare, 81(2), 22-29.

Gruchmann, T. (2005). Safety first: The impact of usability on patient safety. Biomedical Instrumentation & Technology, 6, 462-465.

Kohn, L.T., Corrigan, J., & Donaldson, M.S. (2000). To err is human: building a safer health system. Washington, D.C.: National Academies Press.

Larson, E. (2002). Measuring, monitoring, and reducing medical harm from a systems perspective: a medical director’s reflections. Academy of Medicine, 77, 993-1000.

Medical Dictionary. (2010). Patient. Web.

Merriam-Webster Online Dictionary. (2010). Patient. Web.

Ponte, P., Connor, M., DeMarco, R., & Price, J. (2004). Linking patient and family-centered care and patient safety: The next leap. Nursing Economics, 22(4), 211-215.

Ralston, J.D., & Larson, E. B. (2005). Crossing to Safety: Transforming healthcare organizations for patient safety. Journal of Postgraduate Medicine, 51(1), 61-67.

Walker, L.O., & Avant, K.C. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Prentice-Hall.