To Err is Human . . . To Improve Elusive?

Hospital Bed-2/Timm Suess, via Flickr

Peggy McDaniel, BSN, RN, is an infusion practice manager and occasional blogger

As a nurse working in the quality improvement and patient safety arena, I’m not surprised that the title of a recent article at Fierce Healthcare got my attention: “Hospitals Are Bad for Your Health.” The article highlights a recently released report from the Department of Health and Human Services Office of Inspector General based on a study of Medicare patients discharged in 2008. Among other things, it revealed that “44% of adverse or temporary harm events were clearly or likely preventable.” The usual culprits were to blame:

  • infections
  • medication errors
  • surgery-related errors
  • patient care issues

Most of these have been previously labeled as “never events” by the Centers for Medicaid and Medicare Services (CMS), and currently hospitals are not being reimbursed for the costs incurred if one or more of these happen to a patient while in the hospital. CMS was the first to implement such a pay-for-performance model—and major insurance companies have followed their lead.

In recently published NEJM study, 63% of the adverse events reported in the hospitals studied were deemed preventable. This study was disheartening because we recently passed the 10-year anniversary of the release of the Institute of Medicine’s Report, “To Err is Human,” (pdf) and now know that real progress to reduce harm to patients has been moving at a snail’s pace.

As I blogged here previously, there have been some pockets of significant improvement, such as the implementation of checklists. That said, we have a long way to go to reduce the occurrence of preventable harm to our patients. This statement from the article I began this post with, that “hospitals kill an estimated 180,000 people a year due to adverse events,” should get your attention. It certainly kept me reading.

I also hope it is a call to action for nurses, since we are often the last stop before a medication or treatment touches a patient. Nurses have improved the quality of care and promoted a culture of safety at their respective facilities by

  • promoting the use of checklists in both surgery and procedures.
  • encouraging their hospital administrations to invest in technology that can protect patients.
  • taking responsibility for the care we personally give while also mentoring new nurses.

Nurses have an unprecedented opportunity to better our health care system and the care delivered to every patient. As AJN’s Shawn Kennedy wrote here recently, the entire structure of health care is changing—and nurses will be needed. As the situation now stands, hospitals will be forced to do more with less when preventable adverse events cost them even more in lost reimbursements. It’s a vicious cycle, and we nurses can do much to stop it.

What has your hospital implemented to promote patient safety? What has worked, and what do you think could be better? Are nurses included in the decision-making process when implementing new equipment or policies? How are you making sure you provide safe care to your patients each shift? What more can be done?

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2016-11-21T13:14:47+00:00 December 1st, 2010|nursing perspective|3 Comments
Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Peggy December 6, 2010 at 5:33 pm

    I just noticed a new post by a blogger I admire. Some of the responses are exactly what I was looking for with this post… check it out!!comment=1

    My mantra is “Greater Safety through Standardization of Practice” but it is so hard to get the folks at the bedside to see this is a good thing, not something to make your life miserable.
    I would still love to hear responses as to how to make standardization more palatable…

  2. Vernon Dutton December 6, 2010 at 1:27 am

    Excellent post!

    Two issues that are at the center of hospital healthcare improvement have been left out – as is often the case.

    – The continued utilization of nurses for non-nursing duties and lack of clerical support.

    – The ridiculous unsafe staffing ratios that does not leave enough time to do the minimum of care much less focus on improvement.

    It has already been shown in study after of study that the quality of care and outcomes are related to staffing and if a study was done comparing medication errors and adverse events you would see the same pattern. As you say “Nurses have an unprecedented opportunity to better our health care system and the care delivered to every patient” but it will never happen without reasonable staffing, better utilization and support.

    Vernon Dutton, R.N.

  3. gregdennis December 1, 2010 at 11:13 am

    CMS is at last trying to address the issue of avoidable infections. See our recent blog post on upcoming new rules, at

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