Lesson 6 - Safety Flashcards
Safety Practice Examples
-PPE
-environmental scan
-hygiene
-it’s your move
-pt ID
-preventing aspirations
Accessibility
-right to receive care
-right time
-right setting
-by the right practitioner
Effectiveness
-care achieves expected benefits based on evidence
Efficiency
-waste-free system
-supplies, equipment, time, ideas, information
Patient Safety
-harm is avoided
Patient-centered Care
-respects patient preferences
-culture and values
-make an effort to ask about preferences
Equitable
-care received regardless of gender, ethnicity, location status
1 out of __ hospital admissions, an adverse event occurred
18
Accident
-unavoidable
-unpredictable
Harmful Incident
-resulted in patient harm
Near Miss
-incident that did not reach the patient but would have caused harm if it did
-ie. noticing faulty equipment and not using it
No Harm Incident
-incident reached the patient but no discernible harm resulted
Patient Safety
-reduction and mitigation of unsafe acts within the healthcare system
-use of best practices that lead to optimal patient outcomes
Patient and Provider Factors Influencing Safety
-personal characteristics of each individual
-personal wellness
-age, weight, mood, illness, knowledge, fatigue, stress
Task Factors
-workload
-time pressure
-staffing levels
Technology Factors
-what kind is used
-efficacy
-breakdown
Environmental Factors
-considered the physical work environment
-spills
-clutter
-noise
-lighting
Organizational Factors
-structural
-cultural (personal, unit)
-policy-related
-institution characteristics
Canadian Patient Safety Institute
-2008
-patient safety framework
-goal: multidisciplinary approach to safe patient care
-key knowledge, skills, attributed
CPSI Domains
- culture of patient safety
- work in teams
- communicate effectively
- manage safety risks
- optimize human and environmental factors
- recognize, respond, disclose adverse effects
CPSI Patient Focus
-encourage patient and family advocacy
-publications for the public
Reporting Culture
-need for trust
-no fear of punishment
-learn from it
Informed Culture
-awareness of potential safety issues
-posters
-education days
-communication
Flexible + Learning Culture
-team work
-shared power (work with patient)
-scope of practice
-lifelong learning
Swiss Cheese Model
-organizational system
-focus of most safety conceptual models
-no blame, shame, name
-analyzes the system
-holes in the cheese are weakness in the system
-the pieces of cheese are barriers
-when the hazardous holes line up, losses happen
Iceberg Conceptual Model
-root cause analysis
-looks for contributing factors/root causes over direct cause
Staff Safety Risks
-chemicals, hazards
-IPC
-violence from patients and families
Patient Safety Risks
-falls (90% of safety incident)
-procedure related accidents
-medication errors
-improper skill execution
-equipment related accidents
Developmental Risk Factors
-infants and children (poisoning, drowning, car seat)
-adolescents (risky behaviours)
-adults (lifestyle)
-older persons
Individual Risk Factors
-impaired mobility
-sensory or communication impairment
-lack of safety awareness
Most Common Healthcare Errors
-medication
-transfusion
-errors during surgery
-restraints
-falls
-burns
-pressure injuries
-wrong patient
If an event occurs…
-disclosure (how incident was handled, future minimization plans, regret for the event)
-anticipate reaction
-plan for support
Reporting and Learning System (RLS)
-incident reporting system for AHS
-ie. broken equipment, close calls, the event (harm or not)
-don’t document RLS in patient records, document what happened and what you did
Nurse Role In Patient Safety
-assist client to make needs
-reduce physical hazards
-IPC
-sanitation
-pollution
