Patient Safety

Author(s):
Elizabeth Monsees, PhD, RN, CIC, FAPIC Antibiotic Stewardship Program Manager

Senior Patient Care Services Researcher
Patient Care Services Research
Children’s Mercy Kansas City
Kansas City, MO
Assistant Professor
University of Missouri – Kansas City, School of Medicine

Published:
December 31, 2020
Declarations of Conflicts of Interest:
  • Elizabeth Monsees reports no conflicts of interest.

Abstract

"If you know how to prevent infections, you know how to protect patients from most adverse events." Ref 18-1 Kohn L, Corrigan J, Donaldson M. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. - You do not have permission to view this object.  The patient safety movement in this country is thought to have begun in 1999, with the publication of the Institute of Medicine's report To Err is Human. Ref 18-1 Kohn L, Corrigan J, Donaldson M. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. - You do not have permission to view this object.  In fact, formal efforts to keep patients safe began in the United States with the development of hospital infection prevention and control programs in the 1960s, and globally, even as far back as the mid-1800s, when Hungarian physician Ignaz Semmelweis and British nurse Florence Nightingale publicized the value of hand hygiene as an infection prevention technique. Every year, about 1 in 25 U.S. patients is diagnosed with a healthcare-associated infection Ref 18-2 Centers for Disease Control and Prevention. Healthcare-associated infections (HAIs). Published December 14, 2017. Accessed August 24, 2020. - You do not have permission to view this object.  and more than one million HAIs occur across the American healthcare system. Ref 18-3 Agency for Healthcare Research and Quality. Health care-associated infections. Updated September 2019. Accessed August 24, 2020. - You do not have permission to view this object.  Recent data suggests that more than 400,000 deaths occur each year due to medical error.Ref 18-4 Makary MA, Daniel M. Medical error - the third leading cause of death in the US. BMJ. 2016;353:i2139. - You do not have permission to view this object.  These data demonstrate the critical link between infection prevention and control and improving patient safety.

Although the statistics on medical errors have been widely scrutinized, one cannot cast a blind eye toward preventable deaths attributed to medication errors, falls, wrong-site surgeries, missed diagnoses, or misidentified patients. There have been a public outcry and a national call to action to address this epidemic and focus on preventing all healthcare-associated adverse events. Every healthcare professional, at every level and across all healthcare settings, has been challenged to develop and implement programs to actively seek out risk and document harm (surveillance/reporting), to proactively design standardized processes and systems (prevention), and to create a culture where everyone with every action is responsible and accountable for patient safety (control).

This chapter is intended to develop a shared language around patient safety science challenges and equip infection preventionists (IPs) with talking points to discuss how many of the key surveillance and infection prevention and control principles are foundational to the mitigation broader patient safety challenges. Ideally, this chapter will highlight the intersection between infection prevention and patient safety; infection prevention is essentially safety in action and thus a necessary and essential contributor to national patient safety efforts.