In the outpatient arena, efficiency is the order of the day. While no one can argue the importance of efficiency, problems occur when it takes precedence over safety. Unfortunately, in the outpatient setting, we are experiencing problems that stem directly from rising patient volumes and a confined focus on expediting patient throughput. Wrong-site surgery and medication mistakes are two examples. According to JCAHO, 58 percent of wrong-site cases occurred in the hospital-based or freestanding ambulatory setting; 29 percent occurred in the inpatient setting. As far as medication mistakes, research based on the MedMARx drug reporting system shows that drug administration errors occur regularly in the outpatient setting. Since August 1998, healthcare facilities have voluntarily logged more than 600 cases of outpatient surgery-specific medication errors into the system. About 14 percent of errors studied required additional patient monitoring or prolonged hospitalization, and one case resulted in near death. Many of the errors are traceable to patient misidentification (such as incorrect addressographs and orders with missing patient names) and nursing oversights.

Here are three steps we can all take to foster a culture of safety in the outpatient environment.

• Make safety a top priority. Leaders of outpatient facilities must articulate the principles that safety is the utmost priority, and that safety is everyone's responsibility. They should do so with an understanding that we are all in this together. Leaders must also encourage everyone involved in patient care to voice safety concerns, and embrace those concerns.
• Put it into practice. Don't take the traditional approach of creating more policies and procedures in an effort to ensure safe practices; this only complicates matters and adds to nurses' administrative burden. Rather, update existing policies and encourage simple steps that promote critical thinking. Take wrong-site surgery, for example. While it makes sense to update surgical site checklists, it also makes sense to call for a ?time-out' just before each procedure in which all OR team members pause to simultaneously verify the site. This simple idea is at the core of current JCAHO recommendations for avoiding wrong-site surgery.
• Speak up. Because they witness the entire episode of care, nurses are uniquely qualified to police safety practices. They must be willing to seek validation when needed, as in the case of unidentified or misidentified patients that can lead to medication errors. They must also be willing to point out flaws in clinical processes even when it means relinquishing professional responsibility. For example, drug errors occur in the outpatient setting in part because outpatient nurses have access to a large stock of medications. However, nurses are not pharmacists. By voicing these concerns, outpatient nurses can play a crucial role in ensuring that the healthcare team properly controls, identifies and stores ?high-alert' medications.

In essence, we need to address safety problems by fixing deficiencies in clinical processes rather than finding fault in individual practitioners. By encouraging a top-down/bottom-up culture in which we empower nurses to voice concerns to receptive leaders, we will better ensure safety for all patients. As an added benefit, we will move away from a ?blame-the-practitioner' mindset and toward a more just culture that places blame on practitioners only when individual incompetence is truly at fault.

Dr. Beyea (sbeyea@aorn.org) is Director of Research with the Association of periOperative Registered Nurses.