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Creating a culture of safety

Safety now has a prominent role in all areas of health care, primarily due to the Institute of Medicine report of medical errors and related hospital deaths in 2000. Most experts agree that we must move away from blaming individual health care providers for mistakes. When errors occur, the most important questions should be why, how, when, and where did it occur-not who did it. Focusing on the system instead of on the individual encourages people to report more errors, which in turn gives us a more complete understanding of the causes of problems. This approach allows the organization as a whole to improve.


This culture of safety focuses on the primary areas of infection control, medication safety, communication, and staffing patterns.


Infection control

Health care workers' needle-stick injury rates are decreasing because of new technology and better safety-engineered mechanisms. Improved devices include catheters for cannulating blood vessels and devices for administering I.V. medication through injection ports. Using these devices decreases the risk of occupational exposure to bloodborne pathogens and disease transmission.


The nursing staff must accept new safety devices, learn to use them properly, and then use them consistently. Acceptance depends on several factors, such as having an organizational culture that focuses on safety rather than blame and high-quality training for nursing staff who will be using the device.


Nosocomial (health care-associated) infections are now the most common complication of hospitalized patients, with 5% to 10% or about 2 million acute care patients acquiring one or more infections. These infections cause 90,000 deaths and cost almost $4.5 billion annually. The alarming numbers make reducing the incidence of nosocomial infections a crucial aspect of patient safety.


The four major types of nosocomial infections are pneumonia, infection related to I.V. devices, surgical site infections, and infection related to urinary catheters. Of these, the least common but most deadly and costly is bloodstream infection associated with I.V. devices. The incidence of bloodstream infections is almost three times greater now than it was 30 years ago.


A small percentage of bloodstream infections are caused by short peripheral venous catheters, according to reports in clinical studies, but because these devices are so widely used, they're associated with a large number of serious or deadly infections every year. Reported infections include local site infection, osteomyelitis, septic thrombophlebitis, endocarditis, lung abscess, and brain abscess. One report found that an HIV-infected patient with a peripheral venous catheter is more likely to develop bloodstream infection than an HIV-infected patient who didn't have a peripheral catheter. In another study involving more than 2,000 peripheral venous catheters, about one-fourth of catheter hubs were found to be contaminated with coagulase-negative staphylococci after catheter removal. These published reports suggest that infections from peripheral venous catheters aren't as rare as once thought.


The concept of a closed infusion system has been applied to fluid containers and administration sets for quite a while; now this concept's being applied to the I.V. catheter system. A traditional over-the-needle catheter requires the addition of a short extension set or needleless access connector or both. A closed I.V. catheter system combines these three devices into one system, eliminating the need to connect the extension set to the catheter hub. The closed catheter system prevents blood spills, reduces vein trauma, and decreases the potential for contamination while making this connection.


Infection control measures for peripheral infusion therapy should focus on these factors:


* requiring meticulous hand hygiene for health care workers


* disinfecting the patient's clean skin with an appropriate antiseptic before catheter insertion and during dressing changes. A 2% chlorhexidine-based preparation is preferred for adults and children older than 2 months.


* using single-dose vials for parenteral additives or medications whenever possible


* maintaining aseptic technique during catheter insertion and care.



Hand hygiene with alcohol-based hand rubs is effective against a broad spectrum of bacteria, viruses, and fungi. Easy access to these agents at the point of patient care provides an effective means of infection control and reduces the time a nurse needs to disinfect her hands.


The Joint Commission on Accreditation of Heathcare Organizations (JCAHO), Centers for Disease Control and Prevention (CDC), Infusion Nurses Society (INS), and Institute for Safe Medication Practices (ISMP) all strongly recommend using single-dose containers to help prevent bloodstream infections. Outbreaks of malaria, hepatitis B and C, and HIV have been attributed to the use of multidose vials of saline and heparin to flush catheters. Studies show that many multidose vials aren't labeled with the date opened, are used after their expiration date, and are used for multiple patients.


Using large-volume bags of saline as a source of flush solution has also been responsible for outbreaks of health care-associated bloodstream infections. Single-dose containers may be single-dose vials or prefilled syringes. Single-dose containers don't have a preservative so they must be used only once and then discarded. Never recap a needle or reuse a needle or syringe to make a second connection to the catheter hub or I.V. tubing.


The Institute of Medicine is calling for regulations that would mandate reporting of errors to an external body. Currently, errors are self-reported voluntarily within a facility. In a voluntary system, the burden of completing the internal reports may cause significant underreporting. Some speculate that external reporting will increase the risk of litigation against health care facilities. As the professional organizations and regulatory agencies finalize their recommendations, nurses should be actively involved in documenting serious injuries and medication errors. A better understanding of how and why they occur will only improve patient care.


Four states-Illinois, Pennsylvania, Missouri, and Florida-require public reporting of health care-associated infections. Some thirty others are moving toward mandatory public release of this information. Consumers are demanding more information about the performance of health care organizations so that they can make informed health care decisions.


Some experts are concerned that variations in definitions, data collection methods, and resources to manage the data could lead to unreliable information. The CDC's Healthcare Infection Control Practices Advisory Committee has recently released recommendations to help policy makers seeking to create mandatory public reporting systems for health care-related infections.


Medication safety

The number of adverse drug events per year is conservatively estimated at 1.9 million, with approximately 180,000 of these being life threatening or fatal. The drugs most commonly involved are cardiovascular agents, antibiotics, diuretics, analgesics, and anticoagulants.


Using computer technology to assist with prescribing, dispensing, and administering all medications should improve these statistics (although technology can also introduce or facilitate errors, as recent reports have documented). Infusion pumps now have drugs' concentrations, dosages, and rates programmed into their memory. Mandated by the Food and Drug Administration, bar coding of medications is expected to prevent nearly 200,000 adverse events and transfusion errors over 20 years. Unit-dose dispensing of medications and fluids, including catheter flush solutions, will also rein in errors.



Effective communication between professionals and between departments requires constant attention and improvement. If you get a verbal order from a prescriber, read it back to her and repeat all information clearly and concisely. For instance, instead of saying "fifteen mg," say "one-five milligrams" to prevent any misunderstanding.


Avoid using dangerous abbreviations because these can lead to medication errors. For instance, never use U as an abbreviation for unit. It can easily be misread as a 4 or as a zero, which would make the dose appear to be 10 times greater than intended. Always write out "units."


Each health care organization should determine which I.V. complications will be considered sentinel events, defined by the JCAHO as "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof." Complications of I.V. therapy such as infiltration, extravasation, thrombosis, and infection have a significant risk of loss of limb or limb function, so they qualify as sentinel events. These events require a root cause analysis (a process for identifying the basic or causal factors underlying variation in performance) to understand why errors occur and how they can be prevented in the future.


Infusion therapy is an invasive procedure that can produce serious, life-threatening, or life-altering complications. Patient safety requires close attention from all involved in its delivery. Nurses, pharmacists, physicians, patients, educators, and administrators need to share this responsibility. A culture of safety is important for everyone.




Ballard KA. Patient safety: A shared responsibility. Online Journal of Issues in Nursing. 8(3):4, September 30, 2003.


Burke JP. Infection control-a problem for patient safety. The New England Journal of Medicine. 348(7):651-656, February 13, 2003.


Keepnews D, Mitchell PH. Health systems' accountability for patient safety. Online Journal of Issues in Nursing. 8(3):2, September 30, 2003.


Koppel R, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 293(10):1197-1203, March 9, 2005.


Rivers D, et al. Predictors of nurses' acceptance of an intravenous catheter safety device. Nursing Research. 52(4):249-255, July-August, 2003.