Patient Safety & Quality

Care Movement
University of South Florida
College of Nursing
Hannah Lai
 Introduction & Objectives
Define what is the Patient Safety and Quality
Care Movement (PSQCM)
Explain the origin of the PSQCM
Describe the different types of safety errors
Identify Institute of Medicine (IOM) key concepts
Discuss the significance of PSQCM to the nursing
profession
Discuss the personal significance of PSQCM
Patient Safety and Quality Care Movement
• Patient safety:
• “the prevention of harm to patients”1
• Quality care:
• “the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent
with current professional knowledge”1
• IOM report (1999): To Err is Human: Building a Safer Health System2
• 98,000 hospital deaths per year due to medical errors
• Cost of medical errors
• A “bad apple” problem?

• IOM’s Four-Tiered Recommendation2:

• Enhance knowledge base
• Mandatory and voluntary reporting system
• Raising performance standards
• Implementing safety systems
 Root Cause Analysis
• Goals3
• What happened
• How it happened
• Why it happened
• Prevent recurrence
• Types of safety errors1
• Latent failure
• Active failure
• Organizational system failure
• Technical failure
• Swiss Cheese Model4
 Institute of Medicine (IOM) Concepts

• Crossing the Quality Chasm: A New Health System for the 21st Century5
• The Six Domains of Health Care Quality6:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
 Significance to Nursing
 The “front line” and the “last line”7
 Personal Significance
• Quality and Safety Education for Nurses (QSEN)9
• My goals and contributions as a new graduate nurse:
• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidence-based practices
• Apply quality improvement
• Utilize informatics
 Conclusion

Improve
is a verb

Practice “pivotal
nursing”

Patient safety is the

foundation for quality
care
 References
1. Hughes, R. G. (2008). Patient safety and quality: An evidence-based handbook for nurses. Retrieved from
https://archive.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf
2. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To Err is Human: Building a Safer Health System. Washington, D.C: National
Academy Press.
3. Washington State Department of Enterprise Services. (n.d.). Root cause analysis. Retrieved from
https://des.wa.gov/services/risk-management/about-risk-management/enterprise-risk-management/root-cause-analysis
4. Reason, J. (2000). Human error: Models and management. BMJ : British Medical Journal, 320(7237), 768–770. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770
5. National Academy of Sciences. (2018, January 16). Crossing the quality chasm: The IOM health care quality initiative. Retrieved
from http://www.nationalacademies.org/hmd/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-
Care-Quality-Initiative.aspx
6. Agency for Healthcare Research and Quality. (2016). The six domains of health care quality. Retrieved from
https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html
7. Institute of Medicine (US) Committee on the Work Environment for Nurses and Patient Safety. (2004). Keeping patients safe:
Transforming the work environment of nurses. Washington, DC: National Academies Press (US). Available from:
https://www.ncbi.nlm.nih.gov/books/NBK216190/ doi: 10.17226/10851
8. Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of excellent health care delivery. Nephrology
Nursing Journal, 41(5), 447-456, 505. Retrieved from https://www.annanurse.org/download/reference/journal/patientSafety1.pdf
9. QSEN Institute. (n.d.). QSEN competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas