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NURS 4520: IPC > Class 4 > Flashcards

Class 4 Flashcards

1
Q

what key concepts are found in Giddens r/t safety (2)

A
  • types of pt safety errors
  • attributes & criteria of safe nurses
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2
Q

according to Giddens, what are types of pt safety errors (4)

A
  • diagnostic errors
  • treatment errors
  • preventive errors
  • communication failure
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3
Q

according to Giddens, what are attributes and criteria of safe nurses (3)

A
  • knowledge
  • skills
  • attributes
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4
Q

according to Giddens, diagnostic errors result from… (4)

A
  • delay in diagnosis
  • failure to employ indicated tests
  • use of outmoded tests
  • failure to act on results of monitoring/testing
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5
Q

according to Giddens, treatment errors result from… (4)

A
  • issues w operations, procedures, tests, treatments
  • incorrect drug admin
  • avoidable delays in treatment
  • delayed response to abnormal tests
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6
Q

according to Giddens, preventive errors result from … (2)

A
  • failure to provide prophylactic treatment
  • inadequate monitoring/follow up of prophylactic treatment
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7
Q

according to Giddens, communication failure result from..

A
  • lack of communication/clarity
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8
Q

according to Giddens, what knowledge contributes to safe nurses (6)

A
  • recognize unsafe practices
  • understand the benefits & limitations of safety-enhancing tech (ie. Pyxis machine)
  • reduce reliance on memory by making to-do lists of important safety tasks
  • understand personal/system wide safety risks
  • be able to describe factors which create a culture of safety (ie. organizational error-reporting systems like RL6)
  • understanding the processes used in understanding the cause of error and allocation of responsibility and accountability through such processes as root cause analysis and failure mode effects analysis
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9
Q

according to Giddens, what skills contributes to safe nurses (4)

A
  • use tools which contribute to safer systems
  • build communication skills related to reporting safety hazards
  • learn to educate pts on safety
  • know how to use error reporting systems
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10
Q

according to Giddens, what attitudes contributes to safe nurses (4)

A
  • understand cognitive/physical limits
  • value own role in preventing errors
  • develop attitude of collaboration
  • engage in enviro scanning
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11
Q

what are the key concepts of ISMP Canada Safety Bulletin (2)

A
  • major themes of enablers & challenges to a culture of safety
  • practice tips for student’s role in culture of safety
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12
Q

what practice tips are identified in ISMP Canada’s Safety Bulletin (3)

A
  • encourage students (who bring a new perspective) to identify & report safety errors/gaps
  • ensuring that the preceptors workload accounts for the lvl of supervision each student needs to optimize his/her learning in a safe enviro
  • reviewing organizational challenges impacting students at each facility to identify opportunities to improve the culture of safety
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13
Q

according to ISMP Canada’s Safety Bulletin, what is included in the culture of safety enablers (4)

A
  • ID, resolution, and reporting of incidents (of self or others) by students
  • verification of meds (double checks)
  • dialogue w pts –> students learning about meds to educate pts, help w their own understanding, help catch errors
  • apply recently acquired therapeutic knowledge
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14
Q

according to ISMP Canada’s Safety Bulletin, what contributes to a culture of safety challenges (2)

A
  • preceptor associated
  • gaps in organizational processes
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15
Q

according to ISMP Canada’s Safety Bulletin, what preceptor associated factors contribute to a culture of safety challenges (3)

A
  • availability to students (should be available on-demand questions, check ins)
  • workload balance of clinical tasks & multi-student oversight
  • perpetuation of unsafe practices/workarounds
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16
Q

according to ISMP Canada’s Safety Bulletin, what gaps in the organizational processes contribute to a culture of safety challenges (3)

A
  • timely and complete orientation (at times, tasks were assigned to students before they were adequately oriented & prepped to perform them)
  • definition of roles and responsibilities
  • requirements for clear documentation
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17
Q

what key concepts are found in Brown’s article? (3)

A
  • tame vs wicked problems
  • sources of team conflict
  • barriers to conflict resolution
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18
Q

according to Brown, what are tame problems? what does it require?

A
  • simple pt care
  • requires minimal input by relatively few IPC members
    ex. the flue
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19
Q

according to Brown, what are wicked problems? what does it require?

A
  • a complex set of symptoms with no differentiated care or a pt w complex biopsychosocial issues
  • requires a broad IPC response
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20
Q

according to Brown, what are some sources of team conflict (3)

A
  • role boundary issues
  • lack of understanding of scope of practice
  • accountability
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21
Q

according to Brown, describe what is meant by role boundary issues

A
  • lack of understanding of each other’s roles
  • issues with “who is in charge and who should be doing what”
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22
Q

according to Brown, the contribution of lack of understanding of scope of practice to team conflict is amplified when…

A
  • new disciplines/team members are added to the team
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23
Q

describe the relationship between accountability and team conflict (2)

A
  • physicians may believe themselves to be solely accountable for the pt
  • group mentality is that everyone is accountable for their discipline specific tasks/responsibilities
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24
Q

according to Brown, what are some barriers to conflict resolution (5)

A
  • lack of time to deal w conflict
  • workload issues (=stress/tension)
  • people in less powerful positions
  • lack of recognition or motivation to address conflict
  • avoiding confrontation for fear of causing other team member’s emotional discomfort
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25
Q

according to Brown, describe how people in less powerful positions can be barriers to conflict resolution

A
  • lower power disciplines may feel intimidated, resentful, and often silenced
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26
Q

according to Brown, describe how lack of recognition or motivation can be barriers to conflict resolution (2)

A
  • can lead to failure to recognize the existence of conflict
  • or lack of motivation to address it
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27
Q

according to Brown, describe how ‘avoiding conflict for fear of causing emotional distress’ can be barriers to conflict resolution (2)

A
  • can = not wanting to hurt feelings or offend
  • working in close proximity w coworkers, unit culture of being a “family” may make you feel hesitant to cause drama = may cause people to form cliques
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28
Q

according to Brown, what are strategies for conflict resolution (7)

A
  • developing conflict resolution protocols
  • mediation from leadership (mngmt, individual team leads) –> should be accessible, non-judgmental, good listeners
  • open & direct communication
  • willingness to find solutions
  • showing respect
  • humility
  • communication +++
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29
Q

according to Brown, conflict within & between IPC teams can… (3)

A
  • impede team functioning
  • decrease team effectiveness
  • impact pt care
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30
Q

according to Brown, conflict can be at which 3 lvls?

A
  • micro
  • macro
  • meso
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31
Q

according to Brown, what are examples of conflict at the micro level (3)

A
  • clashing personalities
  • physical space issues
  • issues regarding scope of practice
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32
Q

according to Brown, what are examples of conflict at the macro/meso lvl (2)

A
  • pt volume
  • pt expectations
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33
Q

according to Brown, wicked problems have a higher risk for… why?

A
  • conflict
  • due to differing priorities/pt care plans from each discipline
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34
Q

according to the Canadian Patient Safety Institute, what are the 6 patient safety domains

A
  • pt safety culture
  • teamwork
  • communication
  • safety risk & quality improvement
  • optimize human & system factors
  • recognize, respond to & disclose pt safety incident
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35
Q

what is the Canadian Patient Safety Institute’s definition of ‘patient safety culture’

A
  • actions & behaviors based on shared beliefs and values that enable individuals and organizations to continuously seek to minimize potential pt harm
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36
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘pt safety culture’ (3)

A
  • contribute to the establishment and maintenance of a just culture
  • advocate for improved pt safety culture
  • contribute to the continuous improvement of safety culture
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37
Q

what is the Canadian Patient Safety Institute’s definition of ‘teamwork”

A
  • optimizing teamwork within and across teams to maximize patient safety, quality of care, and health outcomes
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38
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘teamwork’ (6)

A
  • meaningfully partner with patients and families, enabling them to be key members of interprofessional team
  • respect the professional and patient and family roles within the IPC team
  • be vigilant about IPC dynamics to optimize patient safety, quality of care, and health outcomes
  • demonstrate shared authority, leadership, and decision making
  • communicate in a respectful and responsive manner
  • work efficiently with all members of the IPC team to promote understanding, manage differences, and resolve conflict
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39
Q

what is the Canadian Patient Safety Institute’s definition of ‘communication’

A
  • healthcare professionals engage patients and family members in an open dialogue to promote patient safety and to prevent and respond to patient safety incidents.
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40
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘communication” (4)

A
  • demonstrate effective verbal and non-verbal communication skills to promote pt safety
  • demonstrate effective clinical documentation for pt safety
  • communicate to prevent high risk pt safety threats
  • employ healthcare technology to provide safe pt care
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41
Q

what is the Canadian Patient Safety Institute’s definition of ‘safety, risk, and quality improvement’

A
  • identifying, assessing, reducing, and mitigating safety risks to both patients and HCP
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42
Q

according to the Canadian Pt Safety Institute, how is the safety domain of ‘safety, risk, and quality improvement’ accomplished?

A
  • by implementing evidence informed principles of system design and quality improvement
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43
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘safety, risk, and quality improvement) (3)

A
  • anticipate, identify, reduce, and mitigate hazardous routine situations and settings in which safety problems may arise
  • systematically identify, implement, and evaluate quality improvement interventions for pt safety
  • sustain quality improvement and safety practices at a local and system lvl
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44
Q

what is the Canadian Patient Safety Institute’s definition of ‘optimize human & system factors’

A
  • managing the interaction between people (HCP, patient, etc) and other system factors (tools, tech, environment) to optimize patient safety
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45
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘optimize human & system factors’ (4)

A
  • describe the individual and enviro factors that affect human performance
  • apply critical thinking techniques to enhance safe decision outcomes
  • discuss the impact of the human/technology interface on pt safety
  • recognize that human factors are a diverse set of system elements that must be considered in an integrated manner to improve pt safety, & prevent and mitigate hazards
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46
Q

what is the Canadian Patient Safety Institute’s definition of ‘recognize, respond to, and disclose pt safety incidents’

A
  • recognize and report patient safety incidents
  • respond appropriately and effectively to mitigate harm
  • ensure disclosure
  • prevent recurrences
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47
Q

according to the Canadian Pt Safety Institute, nurses should …. r/t the safety domain of ‘recognize, respond to, and disclose pt safety incidents’ (6)

A
  • recognize pt safety incidents
  • engage w pts and families affected by pt safety incidents to meet their needs
  • disclose pt safety incidents
  • learn from pt safety incidents
  • professionally and constructively cope w the emotional stress of being involved in a pt safety incident
  • if in formal leadership role, support pts, families, and HCP involved in pt safety incident
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48
Q

what key concepts are found in Drinka’s article (3)

A
  • 5 approaches to conflict mngmt
  • power currencies
  • disruptive/maladaptive behavior
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49
Q

according to Drinka, what are the 5 approaches to conflict mngmt

A
  • coercing/forcing
  • avoiding/withdrawing
  • compromising/negotiating
  • accommodating/obliging
  • collaborating/integrating
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50
Q

according to Drinka, what are the methods/strategies for the ‘coercing/forcing’ approach to conflict mngmt (3)

A
  • one defensive & one offensive
  • emphasize differences
  • judge & accuse
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51
Q

according to Drinka, describe the power in a ‘coerce-force’ approach to conflict mngmt (2)

A
  • imbalance (real or perceived)
  • attempt to retain imbalance
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52
Q

according to Drinka, what is the conclusion to using a ‘coerce-force’ approach to conflict mngmt

A
  • one yields or standoff
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53
Q

according to drinka, when should the ‘coerce-force’ approach to conflict mngmt be used vs not used?

A
  • use: emergency, unpopular issue, fixed resources, need decision
  • dont: need support or long term relationship
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54
Q

according to Drinka, what are the methods/strategies for the ‘withdraw-avoid’ approach to conflict mngmt (3)

A
  • one defensive
  • one offensive
  • emphasize differences
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55
Q

according to Drinka, describe the power in a ‘withdraw-avoid’ approach to conflict mngmt (2)

A
  • imbalance (real or perceived)
  • attempt to retain imbalance or create new imbalance
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56
Q

according to Drinka, what is the conclusion to using a ‘withdraw-avoid’ approach to conflict mngmt

A
  • one yields or standoff
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57
Q

according to drinka, when should the ‘withdraw-avoid’ approach to conflict mngmt be used vs not used?

A
  • use: trivial issue, little power, nonrecurring problem, part of larger problem
  • dont: critical goals, recurring problem
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58
Q

according to Drinka, what are the methods/strategies for the ‘negotiate-compromise’ approach to conflict mngmt (2)

A
  • bargain
  • hoard info
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59
Q

according to Drinka, describe the power in a ‘negotiate-compromise’ approach to conflict mngmt (2)

A
  • relatively equal
  • attempt to increase relative power
60
Q

according to Drinka, what is the conclusion to using a ‘negotiate-compromise’ approach to conflict mngmt (2)

A
  • different factions agree to accept decision
  • all win and lose
61
Q

according to drinka, when should the ‘negotiate-compromise’ approach to conflict mngmt be used vs not used?

A
  • use: mutually exclusive goals of moderate importance, balanced power, focused on roles
  • dont: early in problem, need more info
62
Q

according to Drinka, what are the methods/strategies for the ‘accomodate-obloge’ approach to conflict mngmt (3)

A
  • share all info
  • clarify all disagreements
  • equalize input
63
Q

according to Drinka, describe the power in a ‘accomodate-oblige’ approach to conflict mngmt (2)

A
  • relatively equal
  • attempt to further equalize power
64
Q

according to Drinka, what is the conclusion to using a ‘accomodate-oblige’ approach to conflict mngmt

A
  • overt agreement; covert disagreement common
65
Q

according to drinka, when should the ‘accomodate-oblige’ approach to conflict mngmt be used vs not used?

A
  • use: when wrong, need social credits, goals not critical, to promote member responsibility
  • dont: issue important to team & relationships
66
Q

according to Drinka, what are the methods/strategies for the ‘collaborate-integrate’ approach to conflict mngmt (3)

A
  • openly present problems
  • use all power strategies
  • balance conflict & cooperation
67
Q

according to Drinka, describe the power in a ‘collaborate-integrate’ approach to conflict mngmt (3)

A
  • universal and unequal
  • members free to get more power
  • however, team controls power for team decision making
68
Q

according to Drinka, what is the conclusion to using a ‘collaborate-integrate’ approach to conflict mngmt

A
  • comprehensive solution & reevaluation
69
Q

according to drinka, when should the ‘collaborate-integrate’ approach to conflict mngmt be used vs not used?

A
  • use: critical needs and goals, ill-defined problem, need comittment
  • dont: no time, no trust
70
Q

according to Drinka, how might team members express emotions (4)

A
  • direct-verbal
  • direct-nonverbal
  • indirect-verbal
  • indirect-nonverbal
71
Q

according to Drinka, describe the ‘direct-verbal’ expression of feelings (5)

A
  • describe feelings (consistent w the core values and ground rules that the team has set)
  • focus on only on point
  • blame others
  • deny one’s actions
  • overdefend a position
72
Q

according to Drinka, describe the ‘direct-nonverbal’ expression of feelings (2)

A
  • withhold info
  • exclude people & essential disciplines
73
Q

according to Drinka, describe the ‘indirect-verbal’ expression of feelings (5)

A
  • raising or lowering voice voice
  • raise unrelated points
  • change opinion when pressured
  • spread guilt
  • verbally attack members over unrelated issues
74
Q

according to Drinka, describe the ‘indirect-nonverbal’ expression of feelings (10)

A
  • silence
  • glaring
  • laugh or grunt
  • sigh
  • obey w animosity
  • avoid eye contact
  • slough or sit erect
  • fold or wave arms
  • tighten facial muscles
  • conceal emotions
75
Q

according to Drinka, what are preferred conflict mngmt styles

A
  • avoiding
  • coercing
76
Q

see pg 166 of Drinka for examples of how to avoid conflict

A

…

77
Q

according to Drinka, what conflict strategies are present in the forming stage of team development (2)

A
  • accommodating
  • coercion
78
Q

according to Drinka, what conflict strategies are present in the norming stage of team development (4)

A
  • scapegoating
  • avoiding conflict
  • working towards equal distribution of power
  • forcing
79
Q

according to Drinka, what conflict strategies are present in the confronting stage of team development (2)

A
  • coercion
  • avoidance
80
Q

according to Drinka, what conflict strategies are present in the performing stage of team development

A
  • constructive confrontation
81
Q

according to Drinka, what are power currencies

A
  • tangible and intangible attributes that are valued by people (respect, morality, knowledge, helpfulness, integrity, etc.)
  • any attribute a person finds attraction
82
Q

according to Drinka, power currencies can be… provide an example

A
  • helpful or destructive
    ex. people can leverage power currencies over others –> “you will lose all respect if you do this”, or used to manipulate others
83
Q

according to Drinka, define disruptive behavior… this is also known as???

A
  • human behaviors in healthcare that have the potential to disrupt care or create an unsafe enviro
  • AKA maladaptive behavior
84
Q

according to Drinka, what are examples of disruptive behavior (7)

A
  • being abusive
  • intimidating
  • demeaning
  • disrespectful
  • dishonest
  • undermining
  • in violation of professional boundaries
85
Q

according to Drinka, disruptive behavior exists on a…

A
  • continuum from occassional to common
  • and mild to severe
86
Q

according to Drinka, what are disruptive behaviors often trigged by?

A
  • stress
87
Q

according to Drinka, what is a solution for disruptive behavior

A
  • more well developed teams where team members stand up for each other and come forward in appropriate behavior is observed
88
Q

according to Drinka, there are both ____ and ___ participants in disruptive behavior

A
  • active and passive
89
Q

according to Drinka, what is the originator of disruptive behavior

A
  • instigator of disrption
90
Q

according to Drinka, what is the receptor of disruptive behavior

A
  • accepts the behavior because the originator is in line with what they believe/value
91
Q

according to Drinka, what is the conduits of disruptive behavior

A
  • people who transfer messages to other receptoras
92
Q

according to Drinka, what is the conduits of disruptive behavior

A
  • people who transfer messages to other receptors
93
Q

according to Drinka, what is the reflectors of disruptive behaviors

A
  • praise the originator and encourage maladaptive behavior
    ex. gossiping about a person you don’t like –> people who value you may spread the gossip
94
Q

according to Drinka, what is the most important step in acknowledging relational team conflict

A
  • to recognize certain behaviors as maladaptive
95
Q

according to Drinka, how many steps are there in recognizing certain behaviors as maladaptive

A

3

96
Q

according to Drinka, describe step 1 of recognizing certain behaviors as maladaptive

A
  • recognize and acknowledge the behavior is occurring
97
Q

according to Drinka, describe step 2 of recognizing certain behaviors as maladaptive

A
  • determine what causes behaviors to increase/intensify
98
Q

according to Drinka, describe step 3 of recognizing certain behaviors as maladaptive (2)

A
  • determine if the behavior is destructive to the team
  • put established procedures in place to address the team member and correct behavior
99
Q

according to Drinka, team members should distinguish between what 3 types of conflict?

A
  • relational
  • task
  • process
100
Q

according to Drinka, describe relational conflict

A
  • revealed when there is a strain between group members that might be expressed as anger, annoyance, exasperation, irascibility, or somehow devaluing another member
101
Q

according to Drinka, describe task conflict

A
  • relates to group members having different ideas over whether a task needs to be performed or the type of task
102
Q

according to Drinka, describe process conflict

A
  • relates to differences in opinions on how to perform a task
103
Q

review table 7.3 in Drinka

A

…

104
Q

what key concepts are found in the ‘Collaborator: Handover’ video (3)

A
  • effectively and safely handing over care is critical to pt safety
  • signif clinically important info is missed during handover reports (40%)
  • standardized handover processes improve pt outcomes
105
Q

according to the ‘Collaborator: Handover’ video, what is the root cause of a majority of pt safety errors?

A
  • communication failures
106
Q

according to the ‘Collaborator: Handover’ video, what is included in pt handover? (4)

A
  • intake
  • discharge to community
  • interprofessional handovers (nurse-nurse)
  • intraprofessional handovers (nurse-OT)
107
Q

according to the ‘Collaborator: Handover’ video, what are the 5 components to effective/safe medical handovers

A
  • standardized
  • limit interruptions
  • whole team should be present
  • verbal & written/elecronic components must both be present (info delivered verbally in report should also be documented elsewhere)
  • ensure quality
108
Q

according to the ‘Collaborator: Handover’ video, how can handovers be standardized

A
  • use ISBAR system
  • or IPASS
109
Q

what is I-PASS?

A

Illness severity
Patient summary
Action list
Situational awareness and contingency planning
Synthesis by receiver

110
Q

according to the ‘Collaborator: Handover’ video, how can we prevent interruptions of handovers

A
  • do not interrupt report unless there is an emergency
111
Q

according to the ‘Collaborator: Handover’ video, why is it important the whole team is present during handover

A
  • allows people to clarify miscommunications & add relevant info
112
Q

according to the ‘Collaborator: Handover’ video, how can we ensure quality in handovers

A
  • there should be audits of pt handovers
113
Q

what are key concepts in the WRHA’s document on Interprofessional Conflict Resolution

A
  • interprofessional conflict resolution occurs when HCP actively engage in addressing disagreements and respond effectively to all types of conflict
114
Q

according to the WRHA’s document on Interprofessional Conflict Resolution, interprofessional conflict resolution involves…. (6)

A
  • acknowledging & validate different perspectives
  • reduce role ambiguity and overload
  • clarifying role differences
  • creating a safe enviro where differing opinions are welcome
  • communicate positively and constructively
  • see conflict w the potential of a positive outcome
115
Q

what are the 6 domains of the Safety Competencies Framework (SCF)

A
  1. pt safety culture
  2. teamwork
  3. communication
  4. safety, risk, and quality improvement
  5. optimize human & system factors
  6. recognize, respond to, and disclose pt safety incidents
116
Q

______ is a critical aspect of high quality healthcare

A
  • pt safety
117
Q

what is included under the domain of “pt safety culture” of the SCF (3)

A
  • integrated pattern of individual and organizational actions & behaviors
  • based on shared values & beliefs
  • clear understanding of one’s role in enhancing a safety culture
118
Q

what is the goal of the domain of “pt safety culture” of the SCF

A
  • minimize the potential for pt harm
119
Q

the domain of “pt safety culture” of the SCF is characterized by… (3)

A
  • authentic/shared leadership
  • timely & responsive communication
  • transparency of shared info
120
Q

what is of paramount importance in the domain of “pt safety culture” of the SCF

A
  • engagement of pts & their families
121
Q

positive safety culture involves…

A
  • a balance of a “no blame system” with individual accountability (aka a “just culture”
122
Q

what is included under the domain of “teamwork” in the SCF

A
  • teamwork within and across teams is optimized to support & maximize pt safety, quality of care, and healthcare outcomes
  • coordinated activities of a multi-system
123
Q

coordinated activities of a multi-team system in the domain “teamwork” includes…

A
  • high performing interprofessional teams that demonstrate competencies and capabilities for safe, effective, and efficient collab pratice
124
Q

each key competency of the domain of “teamwork” in the SCF aligns w…

A
  • one of the 6 CIHC domains, which are foundational to IPC
125
Q

what is included under the domain “communication” in the SCF (4)

A
  • open dialogue w pts & families promote pt safety and prevent/respond to pt safety incidents
  • HCP share & receive info to develop positive IP relationships with and across organizations
  • effective communication builds trust and is precondition of obtaining pt consent
  • clear and consistent info enables informed decision making
126
Q

what are the goals of the domain “communication” in the SCF (2)

A
  • establish partnerships w pts and their families as members of the healthcare team
  • pts to participates as full partners in their own care and shared decision making
127
Q

what is included under the domain of “safety, risk, and quality improvement” in the SCF (3)

A
  • encompasses identifying, assessing, reducing, and mitigating safety risks to pts & HCP
  • HCP require competencies & skills in system-based activities such as teamwork, task mngmt, and situational awareness
  • HCP can learn & apply these skills, and use them to improve healthcare outcomes for pts and their families by preventing or mitigating pt/provider safety incidents
128
Q

the domain of “safety, risk, and quality improvement” in the SCF is accomplished by..

A
  • involving pts, their families, and other HCP in implementing evidence-based principles of system design and quality improvement
129
Q

what is included under the domain of “optimize human & system factors” in the SCF (2)

A
  • managing the dynamic and complex interaction between people & other factors in the healthare system to optimize pt safety
  • poorly designed systems should be addressed by system-lvl changes such as changing culture of healthcare enviro, automating a safety check, and forcing essential functions
130
Q

what individual factors are included in the domain of “optimize human & system factors” in the SCF (8)

A
  • knowledge
  • skills
  • experience
  • personal attributes
  • attitudes and biases
  • work-life balance
  • fatigue
  • other health factors of individual practitioners that constitute key elements of performance
131
Q

what system/enviro factors are included in the domain of “optimize human & system factors” in the SCF (3)

A
  • relationships between policies & procedures
  • work cultures
  • resource allocation in a wide variety of local, regional, national, and international organizational structures
132
Q

what is included in domain of “recognize, respond to, and disclose pt safety incidents” in the SCF (6)

A
  • recognize, respond, and report pt safety incidents to mitigate harm, ensure disclosure, and prevent recurrences
  • importance of culturally sensitive & timely disclosure & acknowledgement of pt’s values, beliefs, and wishes
  • essential to provide factual reasons for what happened
  • recognize pt safety incidents and take responsibility to promptly respond w integrity, professionalism, empathy, and compassion to meet urgent needs/follow up as required for pts & their families
  • team must effectively address pt’s immediate clinical needs/plan for further care
  • provide appropriate apology
133
Q

what are 4 types of errors

A
  • diagnostics
  • treatment
  • preventative
  • communication
134
Q

what are integral to a culture of safety

A
  • teamwork
  • communication
135
Q

what helps create a culture of safety

A
  • implementing formal processes for team handover
136
Q

what are key contributing factors in the occurrence of pt safety incidents (2)

A
  • communication breakdowns (~25%)
  • teamwork failures
137
Q

harm is a term used by WHO and IHI as a reflection of…

A
  • the pt experience
138
Q

what are elements that support safe pt care (6)

A
  • pt and their family as part of team
  • leadership that strives for optimum care delivery
  • culture of safety where one learns & feels safe to report & learn from pt safety incidents
  • support of pt safety from the top
  • honest disclosures r/t pt safety incidents
  • effective teamwork & communication which are taught and reinforced within the organization
139
Q

define: pt handover

A
  • temporary or permanent transfer of responsibility and accountability for some or all aspects of care for a pt or group of pts
  • transfer of essential info & responsibility of care from one care provider to another for the purpose of ensuring continuity in care & safety
140
Q

what are barriers to safe & effective handovers (5)

A
  • setting (busy work enviro and frequent interruptions)
  • time constraints
  • missing pt info
  • lack of standardized communication tools
  • lack of training about safe pt handovers
141
Q

what are recommendations from WHO regarding pt handovers (6)

A
  • use clear & common language
  • limit interruptions
  • avoid distractions (ex, charting, mixing meds)
  • allow enough time for tasks, handovers
  • encourage interactive questioning
  • give sufficient info
142
Q

what is included in maintaining reliable med info

A
  • communicate medication at every transition point in pt care
  • keep med list updated
  • drug name differenced need to be emphasized and clearly communicated
  • WHO recommends using TALL lettering for medication w similar names to differentiate (ex. MAGnolax vs MAOlox)
143
Q

see video on slides for using “CUS”

A

…

144
Q

when does the WRHA recommend a post-event safety huddle

A
  • when a client safety issue occurs
145
Q

what are the beenfits of a safety huddle

A
  • assists the staff, family, and pt’s physical and emotional needs
146
Q

who can a safety huddle be initiated by? how long is recommended? recommended to follow?

A
  • any team member
  • 10 min
  • follow ISBARR
147
Q

describe disclosure to the pt/family after a safety issue occurs (6)

A
  • disclose as close to the event as possible
  • recommend that 2 or more members disclose
  • express regret (“im sorry this happened”
  • inform family that a review will take place
  • stay open to questions
  • provide a name of contact person for future questions

NURS 4520: IPC (5 decks)

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