BUFFALO, N.Y. -- Every time you are admitted to a hospital, you
place your life in the hands of health care professionals. You
trust them to provide the best treatment for you during your stay.
You have no other choice.
However, it has been estimated by the Institute of Medicine
(IOM), that anywhere from 44,000 to 98,000 individuals die in
hospitals every year because of preventable medical error.
How can this be changed? The answer is: nurses. According to the
IOM, nurses are the health care professionals most likely to
intercept and prevent medical mistakes.
The issue has become so important that in 2008 the American
Association of Colleges of Nursing identified patient safety and
quality improvement as the second of nine essentials of
baccalaureate education for professional nursing practice.
The UB School of Nursing is addressing the problem head on by
offering an innovative and engaging patient safety course as part
of its undergraduate curriculum. The course begins with a lecture
from a daughter who lost her mother to medical error, proceeds to
research for how things go wrong and ends with a simulation of how
events leading to the error could have been prevented.
UB assistant professor of nursing, Sharon Hewner, PhD, RN,
herself a patient safety advocate, worked with a curriculum
committee to develop the course called, "Promoting Quality Health
Outcomes and Culture of Safety" that specifically addresses the
ways nurses can raise their patient safety awareness.
Hewner knows that one of the first things beginning nurses can
do to prevent medical errors and improve patient safety is
"Communication is critical and structured communication
techniques can prevent misunderstandings," said Hewner. "Creating
an environment where all members of the health care team, including
doctors, nurses, pharmacists, feel they can speak up about safety
concerns can prevent medical errors."
Hewner designed the course to begin with a human touch: she
invited Mary Brennan-Taylor, a Western New York patient safety
advocate and a colleague on the Niagara Hospice Board on which they
both served, to speak to the class about how her mother died of
preventable medical error.
"After Mary spoke to our class about her mother's experience in
her last six weeks of life, the students asked how her death could
have been prevented. It was an important question," said
From that initial question, Hewner set up teams of students who
researched this case study as to what went wrong, what were the
best evidence-based practice guidelines and how did medications
contribute to the problem. Teams communicated in weekly blogs and
then each team was assigned an episode in the patient's last six
The teams then came to the clinical laboratory and acted out the
way the episode might have had a different outcome if there had
been a culture of safety. Nursing faculty and Brennan-Taylor served
as coaches to guide the students and to give them a simulated
experience of how to communicate more effectively to ensure patient
safety. Finally, the student's summarized what they learned through
the simulation experience and created posters to illustrate what
they had learned.
Brennan-Taylor was impressed by what she observed during the
presentations and simulations noting, "This is an extremely
effective way to teach patient safety -- and, it's innovative. I
don't think anyone is putting it together for students in the way
that UB's School of Nursing is."
What are UB's plans to get the word out about teaching patient
safety in this way for students and practicing nurses at other
institutions? "Right now the plan is to publish about the event as
an innovative approach to nursing education and as a way to engage
students in schools of nursing in patient safety issues," Hewner
said. "The director of the nationwide Safe-Patient Project thinks
that this is something that should be emulated and rolled out
across the U.S."
The University at Buffalo is a premier research-intensive
public university, a flagship institution in the State University
of New York system that is its largest and most comprehensive
campus. UB's more than 28,000 students pursue their academic
interests through more than 300 undergraduate, graduate and
professional degree programs. Founded in 1846, the University at
Buffalo is a member of the Association of American