b'LEADERSHIP GUIDE|research, dedicated to the furtherance of sci- brought to the forefront of safety activi-ence and technology, and to their use for theties. It must NOT be pushed aside.general welfare (MedicineNet, 2016a). In2. Create centralized and coordinated 1863, the U.S. Congress granted the NAS aoversight of patient safety. In order to charter with the authority that requires it tooptimize patient safety interventions, advise the federal government on scientificthere must be oversight conducted by and technical matters (MedicineNet, 2016a). national governing bodies and other The IOM works outside the frameworksafety organizations.of government to provide evidence-based3. Create a common set of safety met-research and recommendations for publicrics that reflect meaningful out-health and science policy (MedicineNet,comes. Organizations must create ways 20166). As part of its mission, the IOMto identify and measure risks and haz-published the first in a series of reports onards proactively. This includes estab-the quality of healthcare in the U.S. Thelishing a system to measure safety and reports authors estimated that there arepatient outcomes across the healthcare between 44,000 and 98,000 deaths per yearcontinuum.from medical errors. The report, To Err is4. Increase funding for research in Human, sent shockwaves throughout thepatient safety and implementation sci-healthcare community and the general pub- ence. It is essential that research be con-lic as well. (Corrigan & Donaldson, 1999). ducted to identify reasons behind safety To say that the 1999 IOM report impactedproblems and optimal ways to prevent nursing practice is an understatement.such problems.Indeed, the entire healthcare community5. Address safety across the entire care had to take a long, hard look at how health- comprehensive strategy to reduce errors incontinuum. Safety issues affect all types care services were delivered in this country.its report, and established a goal to reduceof healthcare facilities, not only inpatient Prior to this report, errors had been treatederrors by 50% over a period of five yearssettings. Safety must be evaluated at all as mistakes made by incompetent profes- (Palatnik, 2016). points in the healthcare continuum.sionals. The IOM report emphasized thatHow close did the healthcare com- 6. Support the healthcare workforce. most errors were not due to incompetence,munity come to achieving this goal? NotWithout adequate support from the but to organizational systems and pro- nearly close enough according to reportshealthcare organizations that employ cesses that fail to prevent errors (Palatnik,published in 2015, 15 years after To Err isthem, healthcare workers cannot func-2016). As organizational leaders struggledHuman was released. Medical errors aretion to the best of their abilities. Failure to improve safety in their healthcare facil- now the third leading cause of death in theto support employees highest profes-ities, a slow, gradual progression towardUnited States (Johns Hopkins Medicine,sional growth contributes to unsafe shared governance occurred. Terms such as2016). Medication errors cause at least oneenvironments. Workplace safety and culture of safety, just culture, and nurs- death every day and injure about 1.3 millionemployee morale and wellness are crit-ing councils, began to signal a new era ofpeople annually in the U.S. (World Healthical to providing safe and appropriate transparency, mutual trust, accountability,Organization, 2017). patient care.and an environment that promotes learningSince significant improvement still needs7.Partner with patients and families for from errors, rather than seeking someoneto be made, what actions do safety expertsthe safest care. It is absolutely necessary to blame (Palatnik, 2016). The report trig- recommend? An expert panel convenedthat patients and families become active gered a realization that all healthcare work- by the National Patient Safety Foundationpartners in determining the plan of care ers at all hierarchical levels are accountable(2015) published a report containing the fol- and determining desired patient out-for the safety of the environments in whichlowing eight recommendations for achiev- comes. Healthcare professionals must they work. ing total systems safety: facilitate accurate and timely sharing Healthcare organizations have had vary- 1. Ensure that leaders establish and sus- of information regarding patient sta-ing degrees of success in implementing cul- tain a safety culture. Organizationaltus, treatment options, and potential tures of safety and shared governance. Theleaders must support, and oversee devel- outcomes.IOM continued to gather data and publishopment and implementation of, a cul- 8. Ensure that technology is safe and reports regarding patient safety and prog- ture of safety. If this has not happened,optimized to improve patient safety. ress (or lack of progress) toward achievingor has been given only lip service with- Technology is critical to communica-safety goals. In 1999, the IOM included aout real change, cultural change must betion among members of the healthcare 12 LEADERSHIP GUIDE|2020| www.elitecme.com'