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Leadership > Module 4 > Flashcards

Module 4 Flashcards

1
Q

Explain a culture of safety?

A

Attitudes, beliefs, perceptions, and values that employees share in relation to safety in the workplace; everyone views and involved in safety because it’s important to all!

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2
Q

Most critical contribution that nursing adds to patient safety is…

A

Our ability to coordinate and integrate quality and safety into patient care because they’re trained to do that

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3
Q

Factors that interfere with culture of safety?

A

Assuming that if no patient is injured then no action is necessary, clinicians don’t want to be blamed, focus is on rules, policies, and procedures

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4
Q

Components of IOM Report

A
  • Medicince & Technology rapidly advanced
  • Healthcare is more complexed
  • Overuse of expensive invasive technology
  • Healthcare system poorly organized & wasting money
  • Delivery of care is complex & error prone
  • Underuse of inexpensive care & services
  • People die from preventable errors
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5
Q

AHRQ’s 8 common Root Causes of Medical Errors

A

*Communication Problems
*Inadequate Information Flow
*Human Problems
*Patient-related Issues
*Organizational Transfer of Knowledge
*Staffing Patterns and Workflow
*Technical Issues
*Inadequate Policies

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6
Q

3rd leading cause of death?

A

Medical errors (Varies depending on research)

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7
Q

Communication problems (AHRQ)

A

illegible handwriting from physician or verbal miscommunication between disciplines

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8
Q

Inadequate flow of information (AHRQ)

A

information not following the patient when discharged or moving to different facility

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9
Q

Human problems (AHRQ)

A

staff don’t follow policies and procedures in place

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10
Q

Patient-related issues (AHRQ)

A

inappropriate pt identification, failure to get consent, inadequate pt education

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11
Q

Organizational transfer of knowledge (AHRQ)

A

Staff or agency nurses not trained adequately

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12
Q

Staffing patterns and workflow (AHRQ)

A

Putting workers in situations where they’re prone to making mistakes (Ex. medsurgRN going to L&D to cover)

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13
Q

Technical issues (AHRQ)

A

complications or failures of medical devices

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14
Q

Inadequate policies (AHRQ)

A

failures in processes

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15
Q

IOM Healthcare Quality Initiative:
STEEEP Principles

A

S = safety
T = timely
E = effective
E = equitable
E = efficient
P = patient-centered

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16
Q

Goal of STEEEP principles

A

to improve health of population, enhance experiences&outcomes, reduce per capita cost of care

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17
Q

10 principles of Redesign of Healthcare

A
  1. Care is based on continuously healing relationships
  2. Care is customized according to patient needs/values
  3. Patient is the source of control
  4. Knowledge is shared and info flows freely
  5. Decision making is evidence-based
  6. Safety is a system priority
  7. Transparency is necessary
  8. Needs are anticipated
  9. Waste is continuously decreased
  10. Cooperation among clinicians is a priority
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18
Q

If something is based on literature, what’s another way to say this?

A

Evidence-based

19
Q

Customized is similar to?

A

Individualized

20
Q

How have principles been applied to nursing?

A

Check PPT

21
Q

6 components of healthcare safety

A

leadership commitment
interdisciplinary participation
evidence-based
education
just culture
patient-centered care

22
Q

What is a “Just Culture”?

A

an approach to emphasize learning and accountability over blame and punishment; does NOT mean there’s no punishment, it is just not the focus.

23
Q

The thought that people, employees, and professionals are going to make mistakes. This describes what?

A

a just culture

24
Q

Human Error

A

Mistake could be design flaws so you TEACH

25
Q

At risk behavior

A

Taking shortcuts; Remove incentives for this behavior and create incentives for good behavior

26
Q

Reckless behavior

A

Blatantly disregarding rules; this behavior is punished.

27
Q

Pros of “Just Culture”

A

Reduced fear of punishment
Fair and consistent justice
Increased report of errors/risks

28
Q

What are the National Patient Safety Goals based on?

A

sentinel events that occur most frequently and once the goal is met its removed from the list and replaced

29
Q

What are the National Patient Safety Goals?

A

Identify patients correctly
Improve staff communication
Use medicines safely
Use alarms safely
Prevent infection
Identify patient safety risks
Improve health care equity
Prevent mistakes in surgery

30
Q

Quality Management

A

mandate for all hospitals to have a quality assessment & improvement in the hospital

31
Q

What is quality?

A

providing the RIGHT CARE, at the RIGHT TIME, for the RIGHT PERSON, in the RIGHT WAY!

32
Q

What is standard?

A

predetermined principle of excellence that serves as a guide for practice (Ex. sponge count during surgery)

33
Q

Quality Improvement

A

assessment and improvement of work process while focusing on what customers want and need

34
Q

What is the model of quality? Explain the cycle.

A

PDSA Cycle
- Plan what you want to do
- Do means carry it out and test of change
- Study the results and determine if it works
- Act is to adopt of modify based on results

34
Q

What is a benchmark?

A

Used to measure standards of quality

35
Q

Name process improvement tools and explain what they do.

A

1) Flow chart: looks at steps that occur; lots of arrows
2) Pareto chart: bar graph that shows frequency of events
3) Fishbone diagram: shows cause and effect; looks at environment, processes, and people
4) Root Cause Analysis: looks at process issues; purpose is to look at systems issues

36
Q

Standards of Quality: Structure

A

internal characteristics of the hospital

37
Q

Standards of Quality: Process

A

activities are done in a way that promote quality

38
Q

Standard of Quality: Outcome

A

Whether or not it made a difference; was it effective

39
Q

Goal of quality management

A

Improve systems and processes; it’s not about whose fault it is, and doesn’t place blame

40
Q

Executive team’s role in quality improvement

A

leads the QI and sets the priorities on what to decrease

41
Q

Nurse manager’s role in quality improvement

A

responsible for quality and safety over the unit; communicate with staff and meet regularly to discuss numbers

42
Q

Staffs’ role in quality improvement

A

uses and promotes quality standards; stay up to date by reading qualities&procedures; report issues; and actively participate

Leadership (13 decks)

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