EXAM 2 Flashcards
What is IOMs 5 core competencies for heath care professionals?
- Provide patient centered care
- Work in interdisciplinary or interprofessional teams
- Employ evidence based practice
- Apply quality improvement
- Utilize informatics
This is a independent, not-for-profit organization that accredits hospitals
The joint commission (JCAHO)
What does TJC set as far as standards for hospitals?
They set high standards for hospitals to increase quality care
Hospitals are responsible for reporting data on their performance based on the:
National Quality Improvement Goals
What is The Joint Commissions’ (TJC) definition of Quality Improvement?
An approach to the continuous study and improvement of the process of providing health care services to meet the needs of patients and others and inform health care policy
What led to an increased awareness of U.S. medical errors?
a report issued in November 1999 by the U. S. Institute of Medicine (IOM)
__________ Americans die every year from medical errors
44,000 (could be as high as 98,000)
More people die from medication errors than:
- MVA
- Breast cancer
- AIDS
What are serious problems with healthcare?
- safety
- quality
- waste
- inefficiency
This report focused on patient safety issues
To Err is human (1999)
This report focused on additional quality problems
Crossing the quality chasm (2001)
This report combined patient and nurse safety issues:
Keeping Patients Safe: Transforming the Work Environment for Nurses (2004)
What happens when errors occur and why is it so important?
- increased cost for pt/hospital and insurance co.
- decrease bonuses or incentives for nurses
- decreased trust from pts
Medicare and medicaid will no longer pay for:
- preventable complications
- hospital acquired
complications (HAC) - serious reportable events
(SREs)
Use _________ to discuss safety and errors:
common language
We need to have ______ standards
data
What kind of systems should be in place?
reporting systems
The 8th leading cause of death in a hospital is:
medication errors
What is included on the official do not use lists for acronyms?
- U/u (units)
- IU (international unit)
- QD (daily)
- QOD (every other day)
- Trailing zeros (write X mg)
- MS (morphine sulfate)
- MSO4 (magnesium sulfate)
What does “pc” mean?
after meals
What does “ac” mean?
before meals
What does “HS” mean?
hour sleep
What are some clinical safety terms?
- Safety
- Error
- Adverse event (no allergies noted but pt breaks out in rash after medication; not fatal and not expected)/Side effect (less serious; unexpected side effect)
- Misuse (pt allergic to medication but was given the medication)
- Overuse (pt has been given too much of the medication or too many meds)
- Underuse (pt doesn’t have insurance so a inferior medication is used)
- Near miss (could have happened but was caught)
- Sentinel event (an event that should not happen)
- Root cause analysis (understanding what the real issue is)
The IOM recommends using _______ to evaluate why patients are harmed by medical care:
PSRS
What are other patient safety reporting systems that can be used?
- PSN
- ICUSRS
What does the incident report system used at UTMB capture?
- Adverse events
- Near misses
- Sentinel events
PSN reported data is ________ and _______
confidential; privileged
What questions are addressed during the root cause analysis matrix?
- What happened?
- Why did it happen?
- What were the most proximate factors?
- What systems & processes underlie those proximate factors?
What is the first step in the process of medication?
Health care provider prescribes the medication (enters order into computer)
What is the second step in the process of medication?
Order goes to pharmacy (errors can occur here)
What is the third step in the process of medication?
Pharmacist reviews/approves order & Phar Tech prepares the medication
What is the fourth step in the process of medication?
Pharm tech sends medication via pneumonic tub or delivers the medication to the patients medication bend or Pyxis
What is the fifth step in the process of medication?
Nurse reviews order and confirms validity before administering the medication
What is HCAPS?
hospital report card
What is quality improvement focused on?
improving work processes to improve patient outcomes and efficiency of health systems
The QI process begins at the:
staff level (magnet recognition program = the best of the best)
Quality improvement is a combination of:
QI and evidence based practice
What areas does QI analyze?
- operational
- quality
- satisfaction
What can we do to improve the quality of patient care?
- Look at the structure
- Look at the process
- Use various QI models/tools:
- Evaluate the outcomes
What is the plan, do, study, act (PDSA) model?
good for an issue that you have time to study and plan for (not life threatening)
What is the rapid improvement event model (RIE)?
this issue must be addressed immediately, no time is available to study or analyze changes must be made ASAP
The “plan” phase of the PDSA model allows for:
- capturing the problem or idea
- planning what you will change and predict for what the impact will be
- plan what information you will collect to measure whether the change has had an effect
The “do” phase of the PDSA model allows for:
- trying out the change on a small scale
- collecting the information required to measure the change
The “act” phase of the PDSA model allows for:
- standardizing your improvement
- deciding whether to make further change
- planning how to improve on the original change made
The “study” phase of the PDSA model allows for:
- analyzing the information collected to understand the impact of the change
- comparing your analysis with the predictions from the plan stage
- summarizing what you have learned
How long does the RIE model allow you to fix the issue?
5 days
What are the team competency outcomes?
- knowledge
- attitude
- performance
What does knowledge within a team embody?
A shared mental model
What does attitudes within a team embody?
Mutual trust and team orientation
What is the two way dynamic interplay?
Interaction between the outcomes and skills is the basis for the team
What does the team leader do?
- Team Leader must be selected *
- Coordinates activities
- Share changes in information
- Gather all necessary resources
What are the different team events that occur?
- brief
- huddle
- debrief
What occurs during a brief?
A short planning session prior to start to:
- discuss team formation
- assign essential roles
- establish expectations and climate
- anticipate outcomes and contingencies
What is the aim of a huddle and what occurs during a huddle?
- problem solving *
- involves a ad hoc team to reestablish situation awareness
- assessing the need to adjust the plan
- reinforcing plans already in place
What occurs during a debrief?
- process improvement
- improve team performance and effectiveness (after action review)
Example of a debrief would be:
after a code; assessing what went well and what areas could be improved to prepare for the next code
You should continue _________ what is happening within a team
scanning and assessing
What is a shared mental model?
Where all team members are on the same page
What is cross monitoring?
An error reduction strategy
What are the components of STEP?
- Status of patient
- Team members
- Environment
- Progress towards goal
What is the IM SAFE acronym used for?
used for nurses to keep themselves healthy
IM SAFE stands for:
I - illness M - medication S - stress A - alcohol and drugs F - fatigue E - eating and elimination
What is the two challenge rule?
Where you can voice concern two times to ensure it has been heard
- The team member being challenged must acknowledge
- If outcome is not acceptable:
> take stronger course of
action (go up chain of
command)
- Empowerment (empowers both team members involved)
What is CUS?
It means STOP THE LINE if a safety breach is sensed or discovered:
- I am concerned
- I am uncomfortable
- This is a safety issue
The DESC script is:
a constructive approach for
managing and resolving conflict
What does DESC stand for?
D: Describe the situation or behavior and provide data
E: Express your feelings or concerns
S: Suggest other alternatives and seek agreement
C: Consequences on team goals; strive for consensus
Collaboration is a:
- mutual solution for the best outcome (WIN WIN WIN)
> commitment to a
common mission - meet goals without comprising relationships
this is a process, not an event
What does SBAR stand for?
- Situation (what is going on with the patient)
- Background (what is the clinical background or context)
- Assessment (what do I think the problem is)
- Recommendation (what would I do to correct it)
What is call out?
a communication tool used to communicate critical information
- informs team members simultaneously during emergent situations
- helps anticipate next steps
- directs responsibility to a specific individual
What is check back?
Process of employing closed loop communication to ensure that information conveyed by the sender is understood by the receiver as intended
What is a handoff?
Strategy designed to enhance information exchange during transitions in care (transfer of information) allowing for the opportunity to ask questions, clarify, and confirm
What are the components of a handoff?
- I PASS THE BATON*
- Introduction (introduce yourself, your role/job and pt)
- Patient (name, DOB, sex, loc)
- Assessment (chief complaint, VS, s/sx, dx)
- Situation (current status, code status, response to tx, etc)
- Safety concerns (critical lab values, allergies, alerts)
- Background (family history, co-morbidities, etc)
- Actions (actions taken and why)
- Timing (level of urgency/prioritization of actions)
- Ownership (who is responsible for pt including family)
- Next (anticipated changes, what is the plan)
TeamSTEPPS is comprised of four teachable-learnable
skills:
- Leadership
- Situation Monitoring
- Mutual Support
- Communication
Delineates fundamentals such as team size, membership, leadership, composition,
identification and distribution
team structure
Ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and that team members have the
necessary resources
leadership
Process of actively scanning and assessing situational elements to gain information, understanding, or maintain awareness to support functioning of the team
situation monitoring
Ability to anticipate and support other team
members’ needs through accurate knowledge
about their responsibilities and workload
mutual support
Process by which information is clearly and accurately exchanged among team members
communication
This is a tool for monitoring situations in the delivery of health care
STEP
Team members protect
each other from ________:
work overload situations
Effective teams place all
offers and requests for
assistance in the context of
patient safety
Team members foster a
climate where it is expected
that assistance will be
actively __________
sought and offered
What is feedback?
Information provided for the purpose of improving team performance
Feedback should be:
Timely – given soon after the
target behavior has occurred
Respectful – focus on behaviors, not personal attributes
Specific – be specific about what behaviors need correcting
Directed towards improvement – provide directions for future
improvement
Considerate – consider a team member’s feelings and deliver negative information with fairness and respect
Assert a corrective action in a
firm and respectful manner by:
- Making an opening
- Stating the concern
- Offering a solution
- Obtaining an agreement
A technique for communicating critical information that requires immediate attention and action concerning a patient’s condition
SBAR
This example of an incoming trauma is: Leader: “Airway status?” Resident: “Airway clear” Leader: “Breath sounds?” Resident: “Breath sounds decreased on right” Leader: “Blood pressure?” Nurse: “BP is 96/62”
call out
What are the steps of a check back?
- Sender initiates the message
- Receiver accepts the message and
provides feedback - Sender double-checks to ensure that
the message was received