and informatics. Recommendations include developing a common language to use across disciplines, integrating learning experiences, developing evidence‐based curricula and teaching approaches, initiating faculty development to model the core competencies, and implementing plans to monitor continued proficiency in the competencies.
Keeping Patients Safe: Transforming the Work Environment of Nurses (2004)The 2004 IOM report links nurses’ work environment with patient care safety and quality. Key recommendations helped shaped nurses’ roles in quality and safety, including the importance of creating a satisfying and rewarding work environment, a learning environment, adequate staffing, support from organizational governing boards, and trust between nurses and organizational leaders. Nurses want a voice in shaping the guidelines and policies for their work to incorporate evidence‐based best practices, effective leadership, and interdisciplinary collaboration.
Identifying and Preventing Medication Errors (2006)Medication errors make up the largest category of error, with as many as 3–4% of US patients experiencing a serious medical error while hospitalized, representing huge economic consequences. A national agenda for reducing medication errors would require collaboration from doctors, nurses, pharmacists, the Food and Drug Administration and other government agencies, hospitals and other health care organizations, and patients.
The second report, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), issued recommendations for sweeping changes in health care systems and proposed the STEEEP model for system changes (Figure 1.1). Goals for system changes are outlined in four recommendations that have spurred many initiatives but few broad overarching improvements and still no national leadership group:
Create a national focus through leadership, research, tool kits, and protocols to enhance knowledge about safety.
Identify and learn from errors by establishing a vigorous error‐reporting system to ensure a safer health care system.
Increase standards and expectations for safety improvements through oversight groups, professional organizations, and health care purchasers.
Improve the safety system within health care organizations to ensure that care improves.
The STEEEP model provides a roadmap for care that is safe, timely, effective, efficient, equitable, and patient centered. Still a relevant performance model, these aims provide the measures of quality and accountability that continue to elude health care, particularly considering the impact of social determinants of health inherent in these measures that continue to present inequalities across health care. Measures from the STEEEP model illustrate how health care system fragmentation and decentralization are barriers to safe quality care. Although the United States spends more than any other country on health care, the system has significant shortcomings, across measures of efficiency, quality, access, safety, and affordability (Kurani and Cox, 2020). For example, patients may see multiple providers who may not be able to share critical patient information due to a lack of technology infrastructure, or providers have a feeling of ownership that precludes sharing information or seeking consultation. Although most data are based on acute care in patient settings, errors in physician offices, outpatient settings, nursing homes, and patient homes are even more troubling due to less oversight, fewer reporting structures, and lack of accountability.
Figure 1.1 2018 Global update on 2001 IOM STEEEP model of health care quality.
Sources: National Academy of Medicine, 2018, Institute of Medicine, 2001, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC.
Education was recognized as the necessary intervention for improving systems of care in the 2003 IOM report, Health Professions Education: A Bridge to Quality. The report outlined a radical redesign for all health professional education to emphasize six core competencies essential for improving twenty‐first‐century health care: patient‐centered care, teamwork and collaboration, evidence‐based practice, quality improvement, safety, and informatics. To integrate the six competencies into nursing, the Robert Wood Johnson Foundation funded the QSEN project, described later in this chapter and more fully in Chapter 3.
Two additional IOM reports, Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2004) and Identifying and Preventing Medication Errors (Aspen et al., 2007), examined the impact of the work environment on quality safe nursing care and the magnitude of medication safety. Nurses are key to improving quality and safety: they are the largest segment of the health care workforce and spend the most time with patients. The 2004 report illustrated how working conditions, environment, leadership support, human factors, roles in decision‐making, and workforce influence safe quality care and stimulated further study on the link between working conditions and relationships on quality and safety outcomes discussed later in the chapter.
Nurses have a central role in medication safety, a complex intervention examined in the fifth book in the series (Aspen et al., 2007). Medication errors are the single largest category of mistakes and often result from interruptions, distractions, poor processes, staffing, and lack of team collaboration of those involved in the medication administration trajectory. On average, inpatients may experience at least one medication error per day. Medication errors account for over 7,000 deaths annually. The US Food and Drug Administration (FDA) investigates more than 100,000 US reports each year of suspected medication errors (https://www.fda.gov/drugs/information‐consumers‐and‐patients‐drugs/working‐reduce‐medication‐errors). Beyond the United States, as many as 4 in 10 patients globally are harmed in primary and outpatient care primarily due to medication usage (Slawomirski, Auraaen, & Klazinga, 2018).
Through the years the IOM Quality Chasm series has remained a relevant primer to examine health care improvement. Primary recommendations, many still unmet, are provided in Textbox 1.1.
Examining Progress: The Impact on Quality and Safety
Twenty years later, health care quality and safety continue to be a major threat. Several progress reports (Leape and Berwick, 2005; Wachter, 2004, 2010; National Patient Safety Foundation, 2015) indicate many core safety actions remain elusive, including interprofessional teamwork, health care–acquired infections, clear communication, and patient‐centered care, and preventable deaths have not lessened. Makary and Daniel (2016) estimate there are 251,454 preventable deaths each year in the United States, although there is still no reliable reporting mechanism because it is difficult to track these through death certificates or patient records and there is continuing reluctance to report sentinel events. Other countries report similar data (National Academies of Sciences, Engineering, and Medicine [NASEM], 2018). Preventable deaths are considered the third leading cause of death in the United States, although in 2020 they were surpassed by the unprecedented deaths from the COVID‐19 pandemic.
Progress has been slow and uneven from the start. Five years after To Err Is Human (IOM, 2000) was released, Wachter (2004) reported five key takeaways:
Initial impact from regulations leveled off after time, indicating regulations alone do not result in lasting change.
Providers have
