1. Hader, Richard RN, CNA, CHE, CPHQ, PhD

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"I've performed this same procedure a thousand times. How could I have possibly made this mistake?" You never forget the first time you hear these words, as you witness your colleagues' anguish upon discovering an error they've made. You immediately feel sympathy because you understand that you, too, have made mistakes. As nurse leaders, we share responsibility with our staff to prevent repetition of the error. We must investigate and analyze errors in an effort to implement procedures and standards that will help prevent harm to patients and assist nurses in the process of delivering safe patient care.

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The Institute of Medicine's report To Err is Human: Building a Safer Health System is a startling reminder that a new culture of patient safety needs to emerge. The report highlights the fallibility of human behavior and the inevitability of mistakes. It further calls for the development of a culture that acknowledges the flaws in the system and the commitment organizations must make to the continuous pursuit of identifying and resolving these deficiencies.


The first step in this process is to encourage the reporting of all errors. When a nurse reports an untoward event, a policy should be initiated that protects him or her from disciplinary action. This may facilitate a more rapid analysis of the situation and prevent others from making the same or similar mistake. Ensure that reporting is as quick and easy as possible. Review a detailed, factual account of the incident so that appropriate education can be administered or changes to the system can be made. Investigate all contributing factors regarding the incident to ensure that each aspect of the incident is analyzed. Make it a point to centralize the information gained from the event within the organization so you can appropriately aggregate it for trending and further analysis. It's frequently determined that when an error occurs, it's not the result of individual performance-rather, an outcome of a poorly managed system.


We need to stay proactive to ensure that the environment we practice in is as safe as possible. Maximizing technology use is one path toward increasing safety. Computerized documentation systems with decision-support capability, medication bar coding, intravenous pumps with programming capability, nurse call bell systems, bed alarms, and medical monitoring devices help nurses keep the environment safe for patients. Create a detailed analysis and system implementation plan to enhance your work environment and improve patient safety.


Allocation of human resources based on patient need is best accomplished through an automated acuity system. By assigning the appropriate number, skill mix, and competency level of nurses, such a system helps minimize poor outcomes based on insufficient human talent at the bedside.


Implementing a unit-based shared governance council that focuses on performance improvement is also essential to safe patient care. The council should focus on both actual and potential events that could cause harm to a patient. Using performance improvement tools helps facilitate the council's work by focusing on opportunities to improve the overall system, not merely individual performance.


Safe, efficient, and collaborative care needs to be the hallmark of nursing. For the next several months, Nursing Management offers a patient safety series, in collaboration with the Institute for Healthcare Improvement, designed to provide you with practical information to improve nursing care. This series starts in this issue with our continuing-education feature. We hope you'll find the content invaluable to your process improvement efforts.