Nure's Role and Quality and Safety Flashcards
What is quality?
excellence of something; usually seen as a scale ranging from low to high quality
What is safety?
avoiding and precenting adverse outcomes for patients
How do quality and safety in healthcare relate?
Healthcare MUST BE SAFE to be considered quality healthcare
BUT truly quality healthcare is more than safe. It is something more
What is quality healthcare defined by IOM’s committee on quality of health care in America?
It must be:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable
Where does preventable medical errors rank in the causes of death in America?
It is the 3rd leading cause of death behind heart disease and cacer
What is safety science?
studies the nature of safety, reasons for mistakes, and systems to ensure patient safety
How is safety looked at now?
It is seen in the context of several professionals instead of just the nurse and patient
What is a culture of safety?
when all members of an organization participate in patient and employee safety
What is an example of culture of safety in action?
reporting near misses, reporting errors/system issues
What can happen if there is a system focused on harsh discipline for mistakes?
Employees will try to hide their errors to avoid getting in trouble
What is a root cause?
the
What is a root cause analysis?
aka RCA
used to see what was the original cause of the mistake or error
What are active errors?
mistakes due to frontline staff actions
What are latent errors?
due to equipment issues/bad maintenance or improper organization
What is a tool used in RCAs?
asking “why?” 5 times (or until root cause is determined) to see the root cause of the error; may reveal possible solutions
What is just culture?
looking at the nature of the error to help determine the proper corrective action for the person who made the mistake
What should happen when a nurse makes a human error?
Nurse should be comforted and they should go over their practice to learn from their mistake
What should happen to a nurse that shows a pattern of human errors?
They should be evaluated
What is at-risk behavior?
when a person is not aware or understand the risk to their nature of behavior
What should be done if a nurse exhibits at-risk behavior?
They should be reeducated so they adopts the standards and correct their behavior
What is the Joint Commission?
The organization that releases patient safety goals for healthcare facilities’ compliance every year–>promoting a culture of safety
What does the Joint Commission encourage facilities to do in response to safety?
They should prioritize making the system safer and not punish people involved in a safety issue. This is to encourage a culture of safety, so people feel comfortable reporting misses and near misses.
What are sentinel events?
When a a patient dies or is critically injured due to a safety error
What is done in response to a sentinel event?
Analyze the environment and what contributed to the mistake. then create solutions to get rid of the chance of the mistake reoccuring
What is QSEN?
quality and safety education for nurses
serves as a basis for knowledge, skills, and mindsets necessary for future nurses
What are the QSEN compitencies?
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement (QI)
Safety
Informatics
What is SBAR?
A communication technique
Situation, background, assessment, and recommendation
What is a incedent report?
aka quality assurance memo, patient safety alert, etc.
a CONFIDENTIAL document (i.e. NOT ON THE PATIENT’S MEDICAL RECORD)
It is a document that describes the aspects of the event in full and patient assessment and interventions. It is filed after an accident or injury
What happens after an incident report is filled out?
Improvements to the system can be made based on the report. THE REPORT USUALLY CAN NOT BE USED AGAINST THE FACILITY OR NURSE
What can contribute to medication errors?
not following through with the 6 rights of medication administration
can happen due to nurse fatigue, short staffing, emergencies
What are safety measures in place to avoid medication errors?
quiet zones in medication cabinets or vests when administering medication, so they are not disturbed
tall man letters (capitalized letters in a name to distinguish medications)
What are safety measures in place to avoid medication errors?
quiet zones in medication cabinets or vests when administering medication, so they are not disturbed
tall man letters (capitalized letters in a name to distinguish medications)
barcodes on meds and on patient wristbands (catch administering wrong meds/dose)
What is ISMP?
The Institute for Safe Medication Practices
they encouraged the Tall Man Letters system to distinguish between drug names
What are common risks for healthcare workers?
blood-borne pathogen exposures, back injuries from lifting, reproductive harm from exposure to antineoplastic meds, and violence from patients/visitors
What are interventions to decrease common healthcare risks?
needleless tools, lifting equipmet, ppe for chemical exposure, alarms, better security, lighting, and more staff
What are “green teams”?
groups of workers that find polluting waste in healthcare settings and recover items that have been considered trash before
What is mistake-proofing?
a way to prevent mistakes. One example is that an NG tube cannot connect with an IV tubing so medication cannot be accidentally put into the stomach and food cannot be accidentally administered in veins
What are ways to decrease mistakes?
mistake-proffing equipment, making checklists, make a habit to check things regularly.
How many nursing errors are due to communication issues?
20%
What are TeamSTEPPS?
Team Strategies and Tools to Enhance Performace and Patient Safety
evidence-based set of tools developed by the Department of Defence and AHRQ
What is AHRQ?
Agency for Healthcare Research and Quality
What is SBAR?
A communication tool a part of TeamSTEPPS
Situation
Background
Assessment
Recommendation
What are common TeamSTEPPS tools?
SBAR
huddles (beginning of shift)
debreifs (after a situation)
What are care bundles?
a consice, specific list that is not meant to replace any other procedure or care already being done
What is CLABSI?
An example of a care bundle
Central line associated bloodstream infection
Hand hygiene
Maximal barrier ppe percautions when line is instered
Prep skin at insertion sit with chlorhexidine
Chose the best catheter site (avoid femoral vein site in adults)
Check on line daily
Remove as soon as it is not needed
Who is known to make care bundles?
Institute for Healthcare Improvment
What is CMS?
Centers for Medicare and Medicaid Services
What is the ACA?
Affordable Care Act
What is the VBP program?
value-based purchasing program
It lets CMS withold a small percentage of hospital reimburesements that do not meet the national standards based on core processes and outcome measures.
If a hospital exceeds standards, they get extra reimbursement
Some is determined my patient satisfaction surveys
What is HCAHPS?
Hospital Consumer Assessment of Healthcare Providers and Systems survey
surveys patients on the effectiveness of communication between providers, patients, pain management, how clean the facility is, and how quiet it was at night
