Class 5-Teaching the Culture of Safety, QSEN, IOM & TJC Flashcards
QSEN
Quality & safety education of Nursing
IOM
Institute of Medicine
TJC
The joint commission
How many die from medical mistakes in US hospitals?
-between 210,000-440,000 pts suffer some type of PREVENTABLE harm that contributes to their death
-medical errors are the third leading cause of death in the USA
-cost of $20 billion dollars/year
Healthcare failures which lead to lapse in safety
-failure to recognize (see nothing wrong)
-failure to rescue (saw & didn’t want to)
-failure to plan (want to know what we’ll do for infrequent events)
Maintaining emergency preparedness avoiding failure to plan
-general preparation
-course specific preparation
general preparation
-CPR training
-fire drills
-code pink drills
-preparing for mass trauma terrorism
course specific preparation
-skills check offs
-simulation grading
-medication calculation quizzes
QSEN competencies
-patient-centered care
-teamwork & collaboration
-evidence based practice
-quality improvement
-safety
-informatics
QSEN defines safety as:
“minimizing risk of harm to patients and providers through both system effectiveness and INDIVIDUAL PERFORMANCE” <– be in the moment; not talking
TJC 2023 National Patient Safety Goals (NPSG) for Hospitals
-identify patients correctly (name & DOB)
-improve safety communications
-use medications safety
-label medications
-medication reconciliation (on at home..is on at hospital?)
-use alarms safety
-prevent infection
-hand hygiene
-identify patient safety risks
-prevent mistakes in surgery
fire safety-RACE
R-rescue (anyone in immediate danger)
A-activate (the fire code and notify appropriate person)
C-confine (the fire by closing doors and windows)
E-evacuate (patients and other people to safe area)
big 3 in safety errors
-medication errors
-falls
-improper use of restraints
1 medication errors
-a medication error is a breakdown or failure at any point in the medication use process
How many die from medical mistakes in US hospitals?
-1.5 million Americans are injured each year by medication errors
-440,000 people die every year from medication errors
-over $3 BILLION annually goes toward treating the consequences of medication errors
-computerized medication ordering systems can prevent 84% of dose, frequency and route errors
Types of medication errors
-omission
-communication
-commission
Omission
missed something
-drug not prescribed
-drug not dispensed
-drug not administered
-drug not taken
communication
-vague instructions (doc gives not full instructions)
commission
something done wrong
-wrong drug or dose prescribed
-wrong drug or dose dispensed
-wrong drug administered
-wrong patient
-frequency timing or duration of the drug is incorrect
-wrong route
-allergic reaction
-drug interaction
characteristics of medication errors made by students during the administration phase: a descriptive study
the authors analyzed reports of drug administration errors by nursing students. they found that omission errors were most common, and that student inexperience and distraction were contributing factors
student nurse medication errors
-COMMUNICATION ERRORS
-duality of patient assignments
-insulin errors
-selecting wrong insulin
-wrong dose/wrong patient
-DOSE OMISSION OF NONSTANDARD TIME MEDS
-administering drugs that are on “hold” or discontinued
-NOT MONITORING VS OR LABS PRIOR TO MEDICATION ADMINISTRATION
-preparing oral meds in parenteral syringes and giving IV (anywhere but gut; nothing in mouth in clean syringe (oral syringes are brown))
-wrong patient when preparing meds for more than 1 patient
student barriers to building a safer culture
near miss-no harm to patient-lack of learning
how do we overcome these barriers?
acceptance of corrective feedback
2 falls
one of the never events
-predicting falls help prevent
5-12-2023 ANA smart brief
-fatal fall rate rises among other adults
-falls killed more than 36,500 people ages 65 and older in the us in 2020, compared with roughly 10,100 fatal falls in 1999, and the age-adjusted fatal fall rate rose from 29 per 100,000 over the study period, according to a research letter in the journal of the American medical association. Jennifer tripken, associate director of the center of healthy aging at the nonprofit national council on aging, says people who survive stroke and heart attacks are at risk for fatal falls, as are people who take multiple medications
fall demographics
-females more than males
-fall risk increased with age over 65 years
-2.8 million older people treated in ED for fall injuries
-800,000 patients a year are hospitalized after falls
-300,000 fall related to hip fractures each year
-falls result in 27,000 deaths annually
-if you are 75 yrs + and fall, you are 4-5 more likely to be admitted to an ECF (extended care facility)
-50% die within 1 year
-cost: $31 billion annually
falls risk factors
->65 years old
-history of falls
-cognitive impairment (dementia; confusion)
-altered gait
-medications
-incontinence
-unsafe environment
-sensory deficits (glasses; hearing aids)
-orthostatic hypotension
-depression
-assistive devices
-confusion or disorientation
-new environment (hospital is new)
fall prevention interventions
-complete fall assessments (epic does)
-frequent rounding
-place on fall precautions
-offer assistance to the toilet Q2
-treaded socks
-bed in low position and bed alarms on
-personal items within reach
-call light within reach/answer call lights promptly
look at slide 23 for epic fall interventions
you can make a difference..look at slide 24
what the evidence shows
2004
-1300 bed hospital over 13 weeks
-183 falls
-average age 64
-most falls unassisted and happened in pt room
-50% of the falls were elimination related
2012
-most falls are toileting related
-confusion increases risk of falls
-beds in low positions prevent falls
-call light use and response time correlate with falls
3 improper use of restraints
-a restraint is any involuntary method CHEMICAL or PHYSICAL of restricting an individual’s freedom of movement, physical activity, or normal access to the body
-ANA believes only when no other viable option is available should restraint be employed
Recommended use of restraints
danger to self & others
-ensure the immediate physical safety of the patient, staff or others
-prevent interruption of therapy
-prevent the confused or combative patient from removing life support equipment or unsafe attempts at mobility
look at restraint pictures on slide 28
the hazards of restraints and side rails (mostly little people)
-impaired circulation
-altered skin integrity
-altered nutrition and hydration
-aspiration/difficulty breathing
-incontinence
-increased possibility of serious injury due to fall
-depression
-anxiety
-death
what the evidence shows
-routine use of restraints does not lower the risk of falls or fall injuries. they should not be used as a fall prevention strategy
-restraints can add to the risk of fall-related injuries and deaths
-limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function
LEARN SLIDE 34 VERY WELL
safety event reports
must be completed after any accident or incident in a health care facility that compromises safety
-describes the circumstances of the accident or incident
-details the patient’s response to the examination and treatment of the patient after the incident
-completed by the nurse immediately after the incident
-is not part of the medical record and completion of a safety event report should not be mentioned in EMR documentation SHARE
performance improvement plans
-near miss medication error (improper dose, med or time identified by instructor prior to administration)
-late arrivals to clinical
-leaving bed in high position
-not identifying the patient prior to med administration
-leaving EPIC open in hallways or patient rooms
-not gloving prior to glucometer or injection
