Primum non nocere, translated as “first, do no harm,” is an axiom familiar to every health care provider. Keeping patients free from harm is embodied in the Nightingale pledge, “… I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.”
While it would be difficult to articulate any known mischievous acts in nursing, we know nurses are highly engaged leading activities to reduce the risk of harm in all settings. Additionally, ANA’s “Code of Ethics for Nurses with Interpretive Statements” spells out our professional responsibility to promote a culture of safety, and articulates personal actions to ensure professional performance predicated on maintaining one’s own health and well-being.
Earlier this year we were shocked and bewildered to learn that medical errors are now the third leading cause of death in the United States, according to Johns Hopkins patient safety experts. Knowing the importance of a culture of safety to promote best practices that keep people safe, ANA has conducted our yearlong campaign, “Safety 360 It Starts with You” to inform and coach nurses about organizational and personal approaches to eliminate the risk of harm and support peak performance of every nurse. Measurable advances have been made in the areas of reducing hospital-acquired conditions, reducing hospital readmissions and lowering costs. Progress affecting the welfare of nurses and other workers, however, is less apparent. Bullying and incivility, manual lifting and moving of patients, inadequate staffing, stress and fatigue continue to take their toll on nurses’ health and well-being.
Despite progress, we see continued harm to patients in part caused by rising stress and burnout among health care providers, including nurses, and new threats that accompany introduction of technologies. The National Patient Safety Foundation’s Lucian Leape Institute details five concepts critical to transforming the safety of our health care system. These include: transparency, patient/consumer engagement, restoration of joy and meaning in work and workforce safety, care integration across delivery systems, and medical education reform in the areas of quality and safety.
The focus on restoration of joy and a workplace environment that supports safety, as well as caregivers, is embodied in what is now referred to as the fourth aim in health care. The “quadruple aim” adds the goal of improving the work life of health care providers, along with the original aims of improved care experience, better population health and lower costs. For nurses, this means ensuring an ethical practice environment and one that supports emotional caregiving, is free of the toxic effects of workplace incivility, violence and bullying, and promotes safe staffing and safe patient handling. It is up to each of us to work with our colleagues and organizational leaders to implement the practices set forth in ANA’s policies on these issues and fight for the resources necessary to impact safety (See www.nursingworld.org/workenvironment).
It is also essential to expose unintended consequences of safety efforts that may introduce harm. For example, protocols and bundles are part of toolkits and guidelines for care but cannot be used absent of clinical judgment and evaluation. Some patients who meet criteria for sepsis alerts may have underlying conditions with contraindications for the treatment plan in a sepsis bundle. And since 2013, studies have indicated hospitals should stop routine use of isolation for patients with MRSA infection, which exposes them to potentially delayed or decreased care associated with being placed in isolation.
Technologies relying on human interaction may also create risk when poor design results in work-arounds; alarm fatigue is a prime example. Additionally, organizational policies can undermine the safe use of powerful tools like the EHR by restricting access to care team members or allowing habits that perpetuate erroneous information. The patient suffers, as was the case of a young woman with an opioid addiction documented in her EHR in numerous entries; she received opioids during and post hospitalization leading to a fatal, unintentional overdose.
Nurses are essential to keeping patients safe. Our work is not done to eliminate harm.
— Pamela F. Cipriano, President, American Nurses Association