Ethical, Legal and Regulatory Flashcards
Certification
voluntary process that serves as a measure of knowledge and competence in the specialty area in which a nurse practices
Credentialing
individual, group or organization has been evaluated by a qualified and objective third party credentialing body and has met standards
Scope of nursing practice
the description of who, what, where, when, why and how nursing practice that addresses the range of nursing practice activities common to all registered nurses
Standards
Authoritative statements of the duties that all registered nurses are expected to perform competently
ANA Scope and standards of Practice
define the expectations of professional nurse in the US
Scope of practice
all healthcare practice is regulated at the state level, nurse practice acts are state specific
Scope of practice implications for NPD practitioners
- align educational activities with the state nurse practice act
- monitor organizational policies for alignment with state nurse practice act
- maintain awareness of scope of practice issues with state legislatures and how it affects individual nurse practice
- recognize the scope of practice for advanced practice nurses within the state
NPD Generalist
BSN with or without certification; MSN without certification
Roles of NPD practioner
learning facilitator, change agent, mentor, leader, champion for scientific inquiry, advocate for NPD specialty, partner for practice transitions
NPD Specialist
MSN with certification
Accredidation
voluntary, granted by non- governmental agencies (Magnet, Pathway to Excellence)
Adverse Event
harm from medical care, not underlying disease (infiltrated IV, pressure injury)
Near miss
an unsafe situation that is indistinguishable from a preventable adverse event. Patient is exposed to a situation but does not experience harm
Never event
events that should never happen
Sentinel Event
serious occurrence that reaches a patient and results in serious harm or death; requires immediate analysis and reporting
Risk Management Process
ideally proactive, identification of hazards, assessment of identified risks, mitigation of risks
Risk management tools
RCA, FMEA
Root cause analysis
retrospective structured analysis of an adverse event that focuses on processes instead of the individual and seeks to uncover problems that increase potential for error
RCA is required by the Joint Commission for sentinel events
True
Steps in RCA
- identify the event to be investigated and gather preliminary information
- charter a team, identify a leader
- describe what happened
- identify contributing factors
- identify root causes- ask why five times for each factor
- design and implement changes to eliminate root causes
- measure the success of changes
Failure Mode Effects Analysis
Prospective, structured analysis of potential problems/adverse events and their effects
Goal is error prevention
Steps in FMEA
- select a process to analyze
- charter a team, identify a leader
- describe the process
- identify what could go wrong during each step
- pick which problems to eliminate
- design and implement changes to reduce or prevent problems
- measure success of changes
FMEA vs. RCA
FMEA- prospective, goal is error prevention
RCA- retrospective, goal is identifying processes and determining how best to move forward
Just culture
a culture in which staff are comfortable reporting errors, maintaining accountability for their own actions
individuals are not held accountable for system failings over which they have not control
Simple human error
an “honest” mistake
At-risk behavior
individual chooses a behavior in which the individual does not recognize the risk or in with the individual perceives the risk to be justified
Reckless behavior
conscious disregard to take a known risk without justification
What is the role of the NPD practioner with event reporting and escalation of incidents?
The NPD practioner is responsible for educating staff on how to report events and communicate incidents and occurrences in the incident command structure according to organizational policy
What is the role of the NPD practioner in educating staff on risk management processes?
- scope of practice for employees
- occurrence and near miss reporting
- just culture
- incident command structures
- staff responsibility to identify risks
What is the role of the NPD practioner in a risk management gap analysis?
Differentiate between learning needs (knowledge, skill or practice), system issues (lack of resources, poorly designed processes) or individual issues (human error, at-risk behaviors, reckless behavior)
Employee sensitive information
employee records, competency, education transcripts, performance records including coaching and disciplinary actions
When should employee’s performance assessments be shared?
Need to know basis only-
What do copyright laws apply to?
print materials, videos, course material, music, media: anything in tangible format
Intellectual Property
any product of the human intellect that the law protects from unauthorized use by others
Who owns materials created by the NPD practioner?
the organization and cannot be shared outside of the organization
What are the alternatives to using copyright materials?
use own photographs and videos, use public domain sites, link to articles, use quotations, purchase graphics, request permission
Commercial Interest
Any entity that makes items that are used or consumed by patients; healthcare goods or services
Commercial Support
A commercial interest organization that pays for education activity
Conflict of Interest
A commercial interest organization that might bias or influence learning activity
Sponsorship
non commercial interest organization supports or funds an educational activity
How to handle conflict of interest
remove individual, revise individual’s role so not relevant, do not offer contact hours, evaluate content for bias and actively monitor activity, evaluate content and obtain participant feedback about commercial bias
How long are CNE records required to be maintained?
Six years
How long are risk management and quality records maintained?
Seven years
How long are accreditation records maintained?
Three years
