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The Institute of Medicine (IOM) reports Crossing the Quality Chasm: A New Health System for the 21st Century (2001) and To Err Is Human(2000) were tipping points in patient safety. The public reaction to these reports was significant. People paid attention. The report energized patient safety research and applications, prompting much needed research and evidence-based practice. It is difficult to find a patient safety article that does not reference at least one of these landmark reports. These early IOM reports were a catalyst for the development of the Doctor of Nurs- ing Practice degree at Purdue University. Subsequent healthcare summits at PurdueUniversity and elsewhere have resulted in common themes, including consumer-drivenhealthcare, basic universal healthcare for all, interoperability of electronic healthrecords, interprofessional education to promote collaboration, and new models of carefor nurse-managed clinic systems. The academic patient safety call to arms occurred in 2003,then the Institute of Medicine publishedHealth Professions Education: A Bridge to Quality.The education report has not enjoyed the media exposure of the earlier two reports, par- tially because talking about education is not as sensational as lost lives. But we who know that the root cause to any issue is complex and convoluted must not lose momentum in solv- ing fundamental education-related patient safety issues. Edu- cation, as a root cause of patient safety issues, is losing livesonce removed. During a root cause analysis, it is always tempting to “re-educate”staff on whatever the identified gap was in the system (Ebright and Rapala, 2003). Without underlying competencies,it is difficult to understand, let alone redesign, patient care pro-cesses. Although many healthcare providers have providedpatient safety education to staff members, and courses are available within some universities, the core competencies mustbe woven into curriculum. |
