The 1999 landmark study titled To Err Is Human: Building a Safer Health System highlighted the unacceptably high incidence of U.S. medical errors and put forth
recommendations to improve patient safety. Since its publication the recommendations in To Err Is Human have guided significant changes in nursing practice in the
United States.
In this Discussion you will review these recommendations and consider the role of health information technology in helping address concerns presented in the report.
To prepare:
Review the summary of To Err Is Human presented in the Plawecki and Amrhein article found in this weeks Learning Resources.
Consider the following statement:
The most significant barrier to improving patient safety identified in To Err Is Humanis a lack of awareness of the extent to which errors occur daily in all
health care settings and organizations (Wakefield 2008).
Review The Quality Chasm Series: Implications for Nursing focusing on Table 3: Simple Rules for the 21st Century Health Care System. Consider your current
organization or one with which you are familiar. Reflect on one of the rules where the current rule is still in operation in the organization and consider another
instance in which the organization has effectively transitioned to the new rule.
Post on or before Day 3 your thoughts on how the development of information technology has helped address the concerns about patient safety raised in the To Err Is
Human report. Summarize in one page how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.
References (mandatory)
PLAWECKI L; AMRHEIN D. Clearing the err. Journal of Gerontological Nursing. 35 11 26-29 Nov. 2009. ISSN: 0098-9134.
Wakefield M. K. (2008). The Quality Chasm series: Implications for nursing. In R. G. Hughes (Ed.) Patient safety and quality: An evidence-based handbook for nurses
(Vol. 1 pp. 4766). Rockville MD: U. S. Department of Health and Human Services.
Legal Issues
Ive made a mistake. This
simple statement or its mere
thought is enough to strike fear
within the most experienced and
knowledgeable of health care professionals.
No matter how many
times a procedure has been done or
a medication administered there is
always the likelihood of preventable
error. Each year the public
is reminded of the potential for
mistakes as the media report medical
horror stories where for example
unknowing patients have surgery
performed on the wrong body part
a wrong medication administered
or a foreign object errantly left
inside their bodies. These reports
highlight the biggest fear of health
care workerstheir own fallibility.
Through carelessness assumption
overt act or omission the health
care professional can easily err
and cause harm to the patient. In
addition to the pain caused to the
patient health care providers also
understand the devastating impact
that such errors can wreak on their
own personal and professional lives.
The purpose of this article is to
About the Authors
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