In its now-famous 1999 report, "To Err is Human: Building a Safer Health System," the Institute of Medicine (IOM) revealed a hidden epidemic in America.

Medical errors, the IOM stated, injure one in every 25 hospital patients, kill an estimated 44,000-98,000 people each year, and cost the economy $17-$29 billion each year.

In the aftermath of the IOM's bombshell, one might assume nurses now play major roles on the national stage in the effort to reduce medical errors. That assumption, it turns out, is wrong.   

In January 2010, in a Gallup poll of 1,500 opinion leaders from industry, academia and government, the overwhelming majority said nurses should have more influence in reducing medical errors, improving quality of care and coordinating patient care.

In other words, when it comes to health care QI, nurses are underused.

And a recent survey of more than 400 newly licensed RNs from around the country, published in January's The Joint Commission Journal on Quality and Patient Safety, found that 38.6 percent thought they were "poorly" or "very poorly" prepared in nursing school to implement QI measures or "had never heard of" the term QI.

"In nursing, there is almost a contradiction," observed Jean Johnson, PhD, RN, FAAN, senior associate dean for health sciences at George Washington University, Washington, D.C. "If you look at the people within hospitals and nursing homes who are involved in quality improvement committees, you will find nurses, primarily. Yet, nationally, nursing is not at the forefront in carrying the banner of quality."

Few Performance Measures
Frontline nurses "are underutilized in the patient safety process," agreed Nancy C. Elder, MD, MSPH, associate professor and director of research at the University of Cincinnati's Department of Family and Community Medicine.

"Nursing supervisors and administrators are involved in it, but often far removed from nurses who perform day-to-day care on patients," she said. "Those nurses have competing demands on their time and may find that long-term problem-solving to decrease errors is not valued on their units. Fixing an obvious error is important and gets done, but going beyond that to figure out why the error happened and what can be done to reduce it is often seen as taking away from direct patient care." 

Another missing ingredient is the performance measurement. Of the 400 quality measures endorsed by the National Quality Forum "only 12 are nursing-sensitive measures," Johnson pointed out. "They include use of restraints, development of pressure sores, infections via IV lines and catheters. Nurses haven't had input into the development of publicly reported measures to the extent we can and should."

What's more, unlike doctors, nurses have never had direct financial incentives to promote patient safety. "Physicians' professional organizations have units specifically focused on quality measures and their relationship to reimbursement," she said. "Nursing doesn't really have that. Physicians have a much higher stake in the game because quality is linked to payment, whereas nursing salaries and income are not sensitive to quality measures."

Systemic FlawsMedication errors and other mistakes by nurses themselves happen mostly because of overwork, fatigue and flaws within hospital systems, according to Johnson.

"Vials that look the same can cause problems," she said. "When giving doses, nurses might translate a '.1' as a '1'".

Paradoxically, nurses' ingenuity often perpetuates problems. "Nurses are famous for 'working around,'" she noted. "If something doesn't work, we work around it - but that leaves the flaw in the system intact. Or, if a correction is expensive, sometimes an institution will say, 'Well, we'll live with it.' We need strong nursing leaders within those systems to act as effective change agents to fix them."

Poorly-executed patient "handoffs" are another concern. "The hallmark of the effective handoff is not just providing information but responding to questions," said Pat Adamski, MS, MBA, RN, who directs the Joint Commission's Standards Interpretation Group and Office of Quality Monitoring. "The other person must have the ability to ask questions. Most hospitals have well-established processes for handoffs. It's when processes are not followed that errors occur."

Nurses must get involved when opportunities arise within hospitals to prevent errors and improve care, Elder advised. At the same time, though, "nurses can't be expected to participate in these activities and care for a full load of patients," she said. "Safety must receive the same respect and support as patient care."

Regional Workshops
Solutions are under way at the scholastic and professional levels.

A Robert Wood Johnson-funded initiative called Quality and Safety Education for Nurses is presenting 10 regional workshops to train nursing faculty members to incorporate QI into the undergrad curriculum. One workshop has already taken place in San Antonio. The second one is slated for D.C. in April. "We've got to make sure nurses develop the mindset and culture to improve care and have the tools to do it," Dr. Johnson said. 

At the professional level, nurses now help shape the Joint Commission's quality and safety standards. "We have nurse representation on our professional technical advisory groups," Adamski said. "They participate in the standards development and approval process, telling us what topics they think we should be looking at."

Also, the Joint Commission now requires that a hospital's chief nursing officer "is at the table when decisions are made on quality of care," she added. "And we recently enacted standards that hospitals must maintain a culture of safety whereby nurses, among others, feel safe to bring concerns forward."

And a brand new organization, the Nursing Alliance for Quality Care (www.nursingaqc.org), based at George Washington University in Washington, D.C., will focus nursing's many disparate organizations on the common goal of QI. "I think the alliance is one of the most exciting things happening in nursing," Dr. Johnson said. "It is gathering all the national nursing organizations together to bring attention and expertise to quality of care."

Jan Bull, administrative director of the new alliance, added: "A lot of people don't think enough has happened since the IOM report. With nursing the largest of all medical professions and predominantly at the bedside, nurses must be engaged in this discussion. We are creating a venue for nursing to have a voice in the QI process. We are developing materials and a roadmap for moving forward."

Michael Gibbons is a senior associate editor at ADVANCE.