Patient Safety

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

October 3, 2014


"If you know how to prevent infections, you know how to protect patients from most adverse events."1 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.1 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. Currently, between 5 and 10 percent of patients admitted to acute care hospitals acquire one or more infections, representing the most common adverse event affecting approximately 2 million patients each year in the United States. It is estimated that 75,000 deaths and an estimated $33 billion per year reflect the healthcare burden of these complications.2,3,4 5 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 to the additional 50,000 to 100,000 deaths annually caused by medication errors, falls, wrong site surgeries, missed diagnoses, or misidentified patients. There has been a public outcry and a national call to action to address this epidemic and focus on preventing all healthcare-related 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 provides an overview of surveillance and disease prevention and control of the broader patient safety challenges and their role in national patient safety efforts.