Module 4 Flashcards
Explain a culture of safety?
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!
Most critical contribution that nursing adds to patient safety is…
Our ability to coordinate and integrate quality and safety into patient care because they’re trained to do that
Factors that interfere with culture of safety?
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
Components of IOM Report
- 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
AHRQ’s 8 common Root Causes of Medical Errors
*Communication Problems
*Inadequate Information Flow
*Human Problems
*Patient-related Issues
*Organizational Transfer of Knowledge
*Staffing Patterns and Workflow
*Technical Issues
*Inadequate Policies
3rd leading cause of death?
Medical errors (Varies depending on research)
Communication problems (AHRQ)
illegible handwriting from physician or verbal miscommunication between disciplines
Inadequate flow of information (AHRQ)
information not following the patient when discharged or moving to different facility
Human problems (AHRQ)
staff don’t follow policies and procedures in place
Patient-related issues (AHRQ)
inappropriate pt identification, failure to get consent, inadequate pt education
Organizational transfer of knowledge (AHRQ)
Staff or agency nurses not trained adequately
Staffing patterns and workflow (AHRQ)
Putting workers in situations where they’re prone to making mistakes (Ex. medsurgRN going to L&D to cover)
Technical issues (AHRQ)
complications or failures of medical devices
Inadequate policies (AHRQ)
failures in processes
IOM Healthcare Quality Initiative:
STEEEP Principles
S = safety
T = timely
E = effective
E = equitable
E = efficient
P = patient-centered
Goal of STEEEP principles
to improve health of population, enhance experiences&outcomes, reduce per capita cost of care
10 principles of Redesign of Healthcare
- Care is based on continuously healing relationships
- Care is customized according to patient needs/values
- Patient is the source of control
- Knowledge is shared and info flows freely
- Decision making is evidence-based
- Safety is a system priority
- Transparency is necessary
- Needs are anticipated
- Waste is continuously decreased
- Cooperation among clinicians is a priority
If something is based on literature, what’s another way to say this?
Evidence-based
Customized is similar to?
Individualized
How have principles been applied to nursing?
Check PPT
6 components of healthcare safety
leadership commitment
interdisciplinary participation
evidence-based
education
just culture
patient-centered care
What is a “Just Culture”?
an approach to emphasize learning and accountability over blame and punishment; does NOT mean there’s no punishment, it is just not the focus.
The thought that people, employees, and professionals are going to make mistakes. This describes what?
a just culture
Human Error
Mistake could be design flaws so you TEACH
