z

The Patient Safety and

Quality Care Movement

Morgan Butts
University of South Florida
z
Introduction
 Defining the Patient Safety and Quality Care
Movement (PSQCM)
 Types of safety errors

 Institute of Medicine (IOM) concepts

 Significance to the nursing profession

 Personal significance
z
Defining the Movement
 Patient Safety
 The prevention of harm to patients1
 Quality Care
 desired health outcomes and are consistent with current
professional knowledge 1
 To Err is Human (1999) catalyzed the movement 2
 Exposed the prevalence of medical errors
 Quantified the effects of these 3
 z
Types of Safety Errors

 Swiss Cheese Model of

 Active failures 2 Accident Causation 2
 Latent failures 2

 Organizational system
failures 1
 Technical failures 1
 z
Institute of Medicine (IOM) Concepts

 6 aims of the healthcare quality improvement solution 4

 Safe

 Timely

 Effective

 Equitable

 Efficient

 Patient-Centered
 z
Significance to the Profession 1
Safeguards within health care organizations for patient safety:
1. Organizational governing boards that focus on safety

2. The practice of evidence-based management and leadership

3. Effective nursing leadership

4. Adequate staffing

5. Organizational support for ongoing learning and decision making

6. Mechanisms that promote interdisciplinary collaboration

7. Work design practices that defend against fatigue and unsafe work

8. A fair and just error reporting, analysis, and feedback system with
training and rewards for patient safety
z
Personal Significance 5

 Patient- centered care

 Communication

 Evidence-based practice

 Continued learning

 Technology
z
Conclusion

 Safety begins with patient-centered care

 The critical contribution of nurses

 On-going assessment of quality

 z
References

1. Hughes, R.G. (2008). Patient safety and quality: An evidence-based handbook for
nurses. Rockville, MD: Agency for Healthcare Research and Quality.
2. Kim, L., Lyder, C. H., McNeese-Smith, D., Leach, L. S., & Needleman, J (2015).
Defining attributes of patient safety through a concept analysis. Journal Of
Advanced Nursing, 71(11), 2490-2503. doi:10.1111/jan.12715
3. Patient Safety Movement Foundation. (2018). Patient safety movement. Retrieved
from https://patientsafetymovement.org/about
4. Harolds, J. A. (2016). Quality and safety in health care, part VI: More on crossing the
quality chasm. Clinical Nuclear Medicine, 41(1), 41-43.
doi:10.1097/RLU.0000000000001012
5. Bunting, R. F., & Groszkruger, D. P. (2016). From to err is human to improving
diagnosis in health care: The risk management perspective. Journal of Healthcare
Risk Management, 35(3), 10-23. doi:10.1002/jhrm.21205