Patient Safety Standard
D-02 Medication Services (essential)
Medication services are clinically appropriate and provided in a timely, safe, and sufficient manner.
—2008 Standards for Health Services for jails and prisons
A decade ago, the Institute of Medicine launched a quality initiative that placed the issues of patient safety and quality of care at the forefront of health care reform. Today, public and private health care systems alike apply a variety of techniques aimed at ensuring patient safety.
In the correctional health care field, NCCHC is a strong advocate for patient safety and has incorporated requirements for safeguards to prevent adverse and near-miss clinical events in its 2008 Standards for Health Services for jails and prisons.
The IOM defines safety as freedom from accidental injury. In health care settings, the goal of patient safety is pursued through appropriate efforts to avoid adverse events related to errors in diagnosis, medication or treatment. But errors that do not result in patient harm are also to be avoided. An adverse clinical event would occur from switching two look-alike medications (such as Prozac and Doxipen) and giving the wrong one to a patient. A near-miss would be dispensing the wrong medication but not actually administering it.
Patient safety systems use redundancy (double checking) procedures to minimize errors and prevent adverse and near-miss clinical events. However, redundancy and back-up procedures alone do not guarantee that patient morbidity and mortality will be reduced. In fact, patient safety literature now identifies the human factor as an essential element in outcomes. The human factor includes personal issues, task-oriented issues and interactions among staff. Most literature on patient safety calls for cultural changes in health care systems to minimize the human factor.
Personal Issues
Those who lack the knowledge, skill or motivation to improve patient safety are often part of the problem. Unfortunately, some health professionals do not fully appreciate these risks and take a cavalier attitude toward patient safety. Others do care but, due to poor understanding or perhaps a heavy workload, skip the steps designed to prevent errors. In correctional facilities, as in the world outside, it is too easy to become complacent about the status quo, even when safeguards are lacking.
Changes in attitude come when there is a top-down endorsement for a culture of patient safety. Administrators should employ strategies to help health care professionals maintain their interest in quality and safety. Training sessions and staff meetings provide good opportunities to build this culture.
Staff meetings should always reinforce the message that patient safety matters, that attentiveness to what is being done (or not done) is an important aspect of the job. Staff must be strongly encouraged to speak up and promptly report errors or problems that compromise safety. To achieve this culture, it is vital that there be no stigmatization or punitive action toward those who report errors.
Patient safety training should occur in staff orientation, in-services and self-assessment courses, and be incorporated into policies and procedures. Policy and procedure should dictate exactly what to do in an adverse clinical event or near-miss situation. Protocol might address what forms to fill out, who should receive them, corrective steps for different types of errors and other measures.
Task-Oriented Issues
Health system experts are interested in learning how distractions and interruptions in clinical workflow might jeopardize patient safety. A study published last year found 75 distracting events in 406 minutes of observing clinical tasks. These distractions led to 32 interruptions in care; of these, 5 tasks were not completed and 4 were not even remembered by the clinicians. Distractions could result in record-keeping mistakes, impede clinician communication and endanger patients.
Consider the pill line nurse under intense pressure to get the inmates completed before a scheduled and mandatory roll call. Or simply an environment with slamming steel doors, poorly illuminated examination rooms or unavailable health records at clinic appointments. What are the chances of human error occurring under these conditions?
Patient safety concerns are not limited to medication administration or medical records. Distracted health staff may be a root cause of patient falls, hurried staff might skip hand hygiene or an overworked clinician might forget to follow up on an MRI scan.
To minimize risk to the patient, administrators should strive to ensure that health care services are structured—and conducted—with patient safety as a goal.
Professional Interactions
In correctional facilities, health staff must contend with disruptive behavior from inmates and even from other staff members. Such behaviors can lead to preventable adverse events and compromise safety and quality. In a recent study of 4,530 administrators, nurses, doctors and other health professionals at 102 veterans’ hospitals, 77% of the respondents reported having witnessed disruptive behavior by physicians and 65% by nurses, behaviors that were linked with medical errors and patient mortality.
More fundamentally, clear communication among staff is essential to health care delivery. When communication is disrupted or is unclear, safety suffers. Efforts to improve communication and minimize disruptive behavior throughout the facility can improve staff safety and patient safety. Again, this should become part of the culture and reinforced through recognition and awareness, policies and procedures, education and training, discussion forums, and counseling or intervention strategies.
Application of the Standard
NCCHC’s standards have always promoted health care quality and now, in keeping with community standards of care, we are encouraging correctional facilities to be even more aware of, and target, preventable adverse events.
In terms of compliance, we interpret the Patient Safety standard in relation to other standards. For example, patient safety could be viewed as seriously jeopardized if correctional and health care administrators did not adequately resolve systemic problems related to quality (A-06), staffing levels (C-07) or suicide prevention (G-05). Collectively, such issues could point to a bigger problem of a culture that neglects patient safety.
On the other hand, NCCHC would look favorably on a system that identified a potential weakness that could jeopardize patient safety and took steps to correct it.
Correctional facilities often face fiscal and personnel shortages. Adding medical errors to the mix only compounds the problems. When health care delivery systems fail and errors occur, this has a ripple effect, leading to financial woes, litigation, personnel shortages and poor health care outcomes.
NCCHC’s new Patient Safety standard reminds us that leadership should foster a culture of patient safety and error reporting and prioritize the steps taken by health care professionals each day to keep their patients from harm.
[This article first appeared in the Summer 2008 issue of CorrectCare.]
The two research studies cited in this article are as follows:
Collins, S., Currie, L., Patel, V., Bakken, S., & Cimino, J. J. (2007). Multitasking by clinicians in the context of CPOE and CIS use. Studies in Health Technology and Informatics,129(Pt 2), 958-962.
Rosenstein, A. H., & O’Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal on Quality and Patient Safety, 34(8), 464-471.