Authors

  1. Rick, Cathy RN, CNAA, FACHE
  2. Kobs, Ann E. MS, RN

Article Content

[horizontal ellipsis]an organization can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information.1

  
Figure. Cathy Rick... - Click to enlarge in new windowFigure. Cathy Rick
 
Figure. Ann E. Kobs... - Click to enlarge in new windowFigure. Ann E. Kobs

The articles chosen for this issue have a continuous thread of leadership being visibly committed to change and encouragement of staff openly sharing safety information.

 

Bartels and Bednash answer the call from the Institute of Medicine's Recommendation 12: [horizontal ellipsis] leaders within the health professions should [horizontal ellipsis] discuss and develop strategies for (1) restructuring clinical education to be consistent with the principles of the 21st-century health system throughout the continuum of undergraduate, graduate, and continuing education for medical, nursing, and other professional training programs; and (2) assessing the implications of these changes for provider credentialing programs, funding, and sponsorship of education programs for health professionals.

 

Along with changes in the educational systems must come methods for nurse retention and acknowledgment of the value of our colleagues at the bedside. Kurtzman and Kizer through their work at the National Quality Forum in a consensus project endorse an initial set of national performance measures for nursing sensitive care.

 

Real Time Reporting describes a rapid reporting methodology for medication errors. They have "Medication Error-free Stays" as an indicator on their Balanced Scorecard. This has always been a challenge for any organization to get their hands around. In the majority of organizations, such incidents are underreported. But, first to know if you are underreporting, you need to know the actual frequency of errors.

 

Florence Nightingale has much to say about nursing management. When she talks about the need for a nurse to be away-even temporarily, she says, "[horizontal ellipsis] if it does occur, it is only to cause the devoted friend or nurse to be absent fewer hours or fewer minutes from her patient-not to arrange so as that no minute and no hour shall be for her patient without the essentials of her nursing."2

 

Smith's article on supervision of assistive personnel describes a perspective on the state of the practice today. How is it that our patients are never left without the essentials of our nursing, for even a moment in time?

 

Take a journey with the Department of Veterans Affairs (VA); experience their examples of patient and staff safety initiatives in the "On the Scene" section of this edition. You will find inspiration and "ready to use" advise as exemplified by VA nursing leadership.

 

The authors from the University Health System Consortium arm us with valuable data gathered from their Patient Safety Net(R). They demonstrate the usefulness of such information for managers in the creation of a safety culture for their patients and staff.

 

National Patient Safety Goals (2005) of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) directly relate to Medication Safety. The article by Fields and Peterman is very timely as they discuss the implementation of a smart IV medication safety system. They found that the cost of Adverse Drug Events in a 700-bed teaching hospital was $4,685 in 1993. Allowing for inflation, that would be astronomical today!! Desiring to be fiscally responsible we can no longer look at safety as a frill.

 

Sometimes we believe that all of this regulation is just another bright idea from the JCAHO. Couig's article provides a macro view of the impetus for keeping the public and our workers safe. It gives cohesion to all we do in the data-gathering initiatives in our organizations. Our public and our staff depend on us for safety and we have much to do to ensure that "no hour shall be for them without the essentials of our nursing."

 

Cathy Rick, RN, CNAA, FACHE

 

Chief Nursing Officer, Veterans Health Administration, Department of Veterans Affairs, Washington, DC, E-mail: [email protected]

 

Ann E. Kobs, MS, RN

 

President, Ann Kobs & Associates, Inc, Wheaton, Ill, E-mail: [email protected]

 

REFERENCES

 

1. Institute for Healthcare Improvement. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Changes/Develop+a+. Accessed September 23, 2004. [Context Link]

 

2. Nightingale F. Notes on Nursing. Philadelphia, Pa: Lippincott; 1992 Commemorative Edition:21. [Context Link]