Using Systems Thinking to Envision Quality and Safety in Healthcare

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A vision for safe quality care has been acknowledged since the days of Florence Nightingale, who recognized the link between nursing practice and outcomes.1

In 1998, nurses identified the significance of practice errors on poor patient outcomes, and the National Database of Nursing Quality Indicators® was established by the American Nurses Association to monitor how patient outcomes were related to unit-level nursing care.1

The Institute of Medicine report, To Err is Human, highlighted human error as causing nearly 98,000 deaths and over 1 million injuries in U.S. hospitals.2

The report offered opportunities for improving healthcare through total system transformation. The Robert Wood Johnson Foundation answered the call with Quality and Safety Education for Nurses (QSEN) to develop minimum standards for safe nursing practice.3

Once standards were established, national nursing education credentialing bodies responded by requiring that QSEN competencies and systems thinking be integrated into program curricula.4,5

After over a decade of deliberate transformation attempts, system-related errors were still being identified as a primary cause of death in the United States, translating to over 400,000 preventable deaths.6

So, why haven't QSEN and efforts to develop systems thinking resulted in improved safety outcomes? Anecdotal evidence suggests that QSEN competencies and systems thinking aren't well integrated into practice settings. This article seeks to increase awareness of administrative and educator roles in empowering clinical nurses to understand the impact of their actions on patient and organizational outcomes using QSEN competencies and a systems thinking approach.



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