6051 Discussion 1 Building a Safer Health System

The 1999 landmark study titled “To Err Is Human: Building a Safer Health System” highlighted the unacceptably high incidence of U.S. medical errors and put forth recommendations to improve patient safety. Since its publication, the recommendations in “To Err Is Human’ have guided significant changes in nursing practice in the United States.

In this Discussion, you will review these recommendations and consider the role of health information technology in helping address concerns presented in the report.

To prepare:

Review the summary of “To Err Is Human” presented in the Plawecki and Amrhein article found in this week’s Learning Resources.
Consider the following statement:
“The most significant barrier to improving patient safety identified in “To Err Is Human” is a “lack of awareness of the extent to which errors occur daily in all health care settings and organizations (Wakefield, 2008).”

Review “The Quality Chasm Series: Implications for Nursing” focusing on Table 3: “Simple Rules for the 21st Century Health Care System.” Consider your current organization or one with which you are familiar. Reflect on one of the rules where the “current rule” is still in operation in the organization and consider another instance in which the organization has effectively transitioned to the new rule.
Post your thoughts on how the development of information technology has helped address the concerns about patient safety raised in the “To Err Is Human” report. Summarize how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.

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Chapter 4. The Quality Chasm Series: Implications for Nursing Mary K. Wakefield

Introduction and Background Exhaustive research documents the fact that today in America, there is no guarantee that any

individual will receive high-quality care for any particular health problem. Health care is plagued with inappropriate utilization of health services and errors in health care practice.1 The quality and safety of health care in this nation were assessed through a series of 11 reports from the Institute of Medicine (IOM). Some of the most significant components of the first two reports are a set of aims to achieve high-quality care and new rules to guide the redesign of the broken health care system. The needed transformation and steps to achieving redesign are substantial because the chasm between what currently exists in health care and what should exist to achieve high-quality care is sizeable. While only four of the IOM reports will be discussed in this section—other reports are discussed in other chapters later in this book—each has significant implications for nursing and for how care should be delivered. 6051 Discussion 1 Building a Safer Health System

In 1999, the IOM released its landmark report, To Err Is Human: Building a Safer Health System.2 The chilling conclusion of that report was that thousands of people were injured by the very health system from which they sought help. Tens of thousands of Americans die each year and hundreds of thousands are injured. That report and its companion, Crossing the Quality Chasm,3 have had a profound impact on how health care is viewed. The information and perspectives moved conversations regarding patient safety and quality care from inside health care institutions to the mainstream of media, corporate America, and public policy. The reports raised awareness of the depth and complexity of quality challenges and prompted the marked expansion of quality improvement efforts through research and other means.

The most significant barrier to improving patient safety identified in To Err Is Human is a “lack of awareness of the extent to which errors occur daily in all health care settings and organizations. This lack of awareness exists because the vast majority of errors are not reported, and errors are not reported because personnel fear they will be punished”2 (p. 155). While these statements describing the essence of the challenges facing health care are simple and straightforward, the level and complexity of effort needed to address them is not. Since the release of the two reports, broad-based efforts have begun to bring more sophistication and precision to measuring and improving the safety and quality of health care. Nevertheless, substantial work in both academic and practice settings remains to be done.

While the IOM reports initiated tectonic shifts in attention and effort, the reports were not the first set of clear statements of concern regarding safety and quality. Nor were these reports the first efforts at calling attention to the need for data, public reporting, and the consideration of health care quality in light of payment for care. More than 140 years earlier, Florence Nightingale, the founder of modern nursing, raised these same issues. In spite of the passage of well over a century between Nightingale and the release of the IOM reports, seemingly little attention was paid in the interim to creating safer health care environments. 6051 Discussion 1 Building a Safer Health System

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.