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  1. Anthony, Maureen PhD, RN

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A colleague and I recently embarked on a research project to study how the concept of safety evolved over time through close examination of 115 years of nursing literature. Little did we know at the outset what an interesting adventure was in store for us. Reading articles by the very first nurses to receive formal professional education made us proud of our legacy. Many of the writers, like Lillian Wald and Virginia Henderson turned out to be leaders and reformers, ahead of their time, and are well known to this day. Other were rank and file nurses, not destined to be remembered 100 years later, but determined to improve practice for other nurses. Too many of the writers were physicians. They wrote on and on about pathophysiology and signs and symptoms, but nothing about actual nursing care. As physicians of course, they weren't experts in patient care, but that didn't stop them from writing authoritatively in nursing journals.

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Nursing didn't have a separate professional identity in the early 20th century. For some, safe patient care meant blindly obeying physician orders. As one writer expressed: "Obedience is as necessary to the nurse as to the soldier in the field... The girl who will obey only when she understands the why and the wherefore of the order is not fitted for the nurses' calling" (Murphy, 1923). Nursing, like medicine, was in its infancy in 1900. With the benefit of more than 100 years of research and advancement in the development of a solid body of knowledge, we can look back with some degree of amusement at treatments such as hydrotherapy, electrotherapy, and insulin shock. And don't forget the enemas, which aimed to treat every illness known to mankind! In those days before antibiotics and immunizations, the energy and attention of the early nurses focused largely on cleanliness, asepsis, and isolation of patients with infectious diseases. Wards were open, housing as many as 40 patients; with all patients in full view, falls were not the risk they are today.


It was clear in our reading that new treatments didn't have to withstand rigorous research or standards. Just about anything could be introduced by anyone with a credential. One particularly worrisome article promoted use of the "baking oven," said to be in use in German hospitals. A gas fire was lit and temperatures were maintained at 200 to 250 [degrees]F. The patient was wrapped in a blanket with an ice bag applied to their head and kept in the oven for 45 to 60 minutes! The oven treatment was said to treat "cases of rheumatism, and nephritis, for gynaecological cases where there is pelvic congestion, in fact for all cases where it is desirable to produce activity of the skin and lower the blood pressure" (Ehrlicher, 1909, p. 106). Most alarming, there are no precautions whatsoever to prevent burns or other untoward effects of baking in an oven! I am glad to say this was the one and only mention of the baking oven.


Lacking other options, a great deal of patient care equipment was homemade. Instructions on building an incubator, hospital bed, or blanket warmer were common. We cringed at the thought of infants in close proximity to hot light bulbs, over-heated intravenous infusion fluids, and the risk of patient injury in homemade beds. Work hours were also long. One nurse advocated for the end of 24-hour shifts for private duty nurses, noting: "In all kinds of industries hours are regulated and precautions taken that no one shall fall asleep at his post and thus endanger the lives of others" (Hansen, 1923, p. 449).


The first article we came across that was devoted solely to safety was in 1939. At this point, professional nursing was about 60 years old in the United States. This provided enough time and experience to recognize possible dangers inherent in healthcare. Only one page long, the writer was truly ahead of her time. She wrote about stair treads and hand rails, stable wheel chairs, well-lighted rooms, bath tub falls, and burns from hot water bottles. A single sentence makes me think homemade furniture was on the way out: "Shaky furniture is dangerous" (Schoofs, 1939, p. 274). This year also brought the first article devoted to medication administration safety. This author was also ahead of her time-reminding nurses that using "official and proprietary names interchangeably" is a source of error. She also recommended standardization with use of either the metric or apothecary system across hospitals and marking patient beds with a card that states the patient's name to prevent drugs being administered to the wrong patient (Faddis, 1939).


I can't help but wonder what we are doing today that will be shocking to nurses and other clinicians100 years from now. Fortunately, the Institute of Medicine and the Joint Commission have made us more aware of patient safety and prevention of errors. Safety is an understudied area of home care. Critically examine safety in your work setting and institute a quality improvement project or research study. Be that clinician who is ahead of the times and pave the way for safer patient care.




Ehrlicher C. (1909). The baking oven. American Journal of Nursing, 10(2), 106. [Context Link]


Faddis M. (1939). Eliminating errors in medication. American Journal of Nursing, 39(11), 1217-1223. [Context Link]


Hansen H. (1923). The private duty nurse. American Journal of Nursing, 23(6), 448-450. [Context Link]


Murphy R. (1923). The Catholic Nurse. Milwaukee, WI: The Bruce Publishing Company. [Context Link]


Schoofs A. (1939). Safety in hospitals. American Journal of Nursing, 39(3), 274. [Context Link]