Improving and Managing Safe and Quality Care Flashcards
Adverse event or patient safety is?
Preventable.
Error of omission is?
An action that is NOT done.
Error of commission is?
Wrong act that IS committed.
Unsafe act?
Presence of a potential hazard - not scanning patient wristbands.
Slips, lapses, and mistakes example?
Giving tylenol to a patient with a 101 degree fever, only to find out that the UAP reported the wrong temperature for the wrong patient.
Near miss?
Before the mistake was carried out.
Sentinel event?
Severe harm to a patient. Example: wrong side surgery.
Person approach to medical errors?
Focus of unsafe acts of health-care professionals and errors as the result of human behaviors.
The system approach to medical errors?
Acknowledge that errors happen because humans are not perfect.
What are the three reasons behind medical errors?
Human factors, communication, and leadership.
How can we avoid medical errors?
Develop a culture for safety, standardize, implement initiatives to improve safety and quality, analyze complex processes, and collect data on errors.
What is the culture of safety?
Provides a blame-free environment in which staff members feel comfortable reporting errors and near misses.
What is a just culture?
Refers to a culture that is fair to those who make an error.
What are autonomic actions?
Being on autopilot.
What does the agency for healthcare research and quality provide?
Provides tips for preventing medical errors and promoting patient safety, and suggestions about measuring health-care quality.
What are structure indicators?
Relate to the care of the environment.
What are process indicators?
Relate to how nursing care is provided.
What are outcome indicators?
Relate to the results of nursing care.
What does the national quality forum do?
Sets standards for all health-care measurements, identifies and accelerates quality improvement priorities, advances electronic measurement to capture necessary data needed to measure performance, provides information and tools to help health-care decision makers, aims to reduce preventable hospital admissions and readmissions, and establishes its own set of nursing-sensitive quality indicators.
Who established national patient safety goals?
JOINT COMISSION EW
What are the four key principles of quality improvement?
Works as systems and processes, focus on patients, focus on being a part of the team, and focus on the use of data.
What are the five QI models?
Donabedian model, six sigma model, IHI model of improvement, failure modes and effects analysis, root cause analysis.
What are some QI tools?
Run chart, bar chart, histogram, fishbone diagram, flow chart, pareto chart.
