Captain and champion: nurses’ role in patient safety

Over the past decade, there has been increasing attention to issues surrounding patient safety and human error in health care and specifically in the critical care area. Adverse events have often been used as indicators of (a lack of) quality and safety in health service delivery. An adverse event has generally been defined as some injuries caused by health care management that prolongs hospitalization and/or results in disability (Thomas et al., 2000). However, some intensive care unit (ICU) researchers have conceptualized adverse events slightly differently. Beckmann et al. (1996) examined ICU ‘incidents’, defined as ‘any unintended event or outcome which could have, or did, reduce the safety margin for the patient (1996, p. 321). A total of seven Australian ICUs reported 610 incidents in one year, grouped into five categories: drugs and therapeutics (28%), procedures, lines and equipment systems (23%), patient management and environment (21%), airway and ventilation (20%), and unit management (9%). A small Italian study identified 67 unintended events in 38 ICU patients over a 4-week period (Capuzzo et al., 2005). More recently, in a US study, Rothschild et al. (2005) identified that of 391 ICU patients, 79 (20.2%) had some form of adverse event. Thus, it appears that a significant proportion of critically ill patients will experience some form of adverse event during their ICU stay. So, what can we do to limit the risks our patients face? While being careful is always important, exhorting nurses to be ‘more careful’ is an insufficient response. The Institute of Medicine’s (IOM) report To err is human to the US congress in 1999 acknowledged the complex nature of error and advocated a more systemic response. Errors occur as a consequence of multiple levels of system failure. Reason (2000) maintains that within a complex system, defensive barriers are designed to protect individuals from situations that predispose to error. Defences exist at organizational, managerial, technological and procedural levels. Individuals, especially nurses, and individual actions are often the last line of defence. The occurrence of, for example, a drug administration error represents failure at all these levels. Incident reporting and the need to develop national incident databases was a major recommendation of the IOM’s report. Aggregated over many institutions, databases allow researchers to more readily identify trends that may not be as evident in particular institutions. National trends can point to national remediation strategies including improved regulation, approval and the development of standards that, Bogner (2004) argues, have the greatest possibility of effecting systemic change. National incident reporting databases also allow specific institutions to compare their profile against the national profile, which may assist in targeting areas in need of improvement. The IOM report acknowledged a number of barriers to developing comprehensive national incident databases. The most significant of these are the risk of litigation and its associated culture of blame, that is, our tendency to overemphasize the actions of individuals in isolation from broader contextual factors. Blaming individuals is the easy option. By attributing error to ‘bad apples’, we avoid the need to assess our own behavior and we avoid the need to reassess the systems we work in, an exercise that can be costly and challenging at multiple levels of management. There is another way. Errors rarely occur without warning. In aviation and other high-hazard industries, ‘near-misses’ are defined as events that if they had been allowed to proceed would have resulted in harm. In these industries, near-misses are routinely analysed because they represent system vulnerabilities or gaps in defensive barriers that can be addressed. Near-miss reporting has a major advantage over error incident reporting. Not only do near-misses expose system vulnerabilities before they lead to actual error but also highlight processes within the system that check against and trap potential errors before they result in harm. Because nurses are often the last line of defence in error scenarios, near-miss reporting is of particular relevance. Nurses are ideally positioned to identify, analyse and act on near-misses. Nurses occupy senior organizational and managerial positions, participate and are located in quality-assurance departments, are extensive users of technology and are involved in the design and improvement of care delivery procedures, and their training in observation, evaluation and assessment specifically equips them with the skills needed to identify and analyse nearmisses. Three changes are needed to strengthen nurses’ capacity to act preemptively in error prevention. First, a greater awareness of error and its causes during nurse training are needed. Currently, underand postgraduate nursing curricula in Australia do not specifically include modules or course work associated with human error and system vulnerabilities. However, recent GUEST EDITORIAL