The Effects of “To Err Is Human” in Nursing Practice

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 week’s Learning Resources.
• Consider the following statement:

“The most significant barrier to improving patient safety identified in “To Err Is Human”is 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 how informatics has assisted in improving health care safety in your organization and areas where growth is still needed.

Reference:
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. 47–66). Rockville, MD: U. S. Department of Health and Human Services. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/WakefieldM_QCSIN.pdf 

Readings

• American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author.
• McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (Laureate Education, Inc., custom ed.). Burlington, MA: Jones & Bartlett Learning.
  • Chapter 1, “Nursing Science and the Foundation of Knowledge”

    This chapter defines nursing science and details its relation to nursing roles and nursing informatics. The chapter also serves as an introduction to the foundation of knowledge model used throughout the text.

  • Chapter 2, “Introduction to Information, Information Science, and Information Systems “

    In this chapter, the authors highlight the importance of information systems. The authors specify the qualities that enable information systems to meet the needs of the health care industry.

  • 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. 47–66). Rockville, MD: U. S. Department of Health and Human Services.
    • Pages 1–12

      These 12 pages highlight the issues raised by the Quality Chasm Series and examine their long-term implications for nursing. The text reviews external drivers of safety and quality, design principles for safe systems, and guidelines for health care redesign.

• Cipriano, P. F., & Murphy, J. (2011). Nursing informatics. The future of nursing and health IT: The quality elixir. Nursing Economic$, 29(5), 282, 286–289.
  Retrieved from the Walden Library databases.

  In this article, the authors focus on how nurses can use health information technology to help transform health care using the recommendations included in the 2010 Institute of Medicine report “The Future of Nursing, Leading Change, Advancing Health.” The author also discusses the 2011 National Strategy for Quality Improvement in Health Care.

• Plawecki, L. H., & Amrhein, D. W. (2009). Clearing the err. Journal of Gerontological Nursing, 35(11), 26–29.
  Retrieved from the Walden Library databases.

  This article presents a summary of the Institute of Medicine report “To Err Is Human: Building a Safer Health System.” The authors provide an overview of what has been accomplished in the decade following the IOM report, focusing in particular on health information technology.

Media

• Laureate Education, Inc. (Executive Producer). (2012e). Introduction to nursing informatics. Baltimore, MD: Author.