Leading the Way to Patient Safety: 1900-2016

Kowalski, Sonja, and Maureen Anthony



Background: Statistics suggest up to 90,000 Americans die each year from healthcare errors. In To Err is Human (2000) the Institute of Medicine urged a retreat from a culture of silence with regard to errors and encouraged fundamental changes to create a culture of safety in all healthcare settings.

Purpose and Theoretical Rationale: The purpose of this study was to explore the historical and contemporary role of nursing in patient safety through content analysis of articles in the American Journal of Nursing (AJN). AJN was chosen because it is the oldest continuous journal for nurses and is directed at practicing nurses. This research was guided by the Hazard-Barrier-Target Model.

Method: Tables of contents for all issues of AJN from 1900 to 2015 were searched for titles that suggested a focus on nursing care or patient safety. Data were examined and contemplated by both researchers in parts and as a whole over 8 months.

Results: Early safety measures centered on asepsis and the newly understood germ theory. Articles were often written by physicians and focused on pathophysiology rather than nursing care. In the 1930s, methods to prevent medication errors were proposed, and written procedures were developed to standardize care. WWII nurses identified improved survival with shock wards and recovery rooms. In the 1950’s staffing patterns were developed to match patient acuity, specialized care for premature infants was instituted, and identification armbands and addressograph plates were introduced. Increasing complexity of equipment and medication regimens in the 1960s led to safety issues. Side rails were emphasized yet lacked evidence. Hospital-acquired infections were recognized. Unit dose medication was instituted in the 1970s. Medication safety and nursing procedure safety took priority in the next two decades. From 2000-2015, articles looked beyond human factors to systemic factors such as communication, lack of a culture of safety, patient-nurse ratios, and skill mix, disruptive behavior, shift work, and long working hours.

Conclusions: Emphasis on safety increased as complexity of care increased. The IOM report was instrumental in creating a culture of safety and stimulated research that focused on systemic solutions to errors.