Patient Safety and Documentation

Question 1

Healthcare Excellence Canada brings together…

Answer 1

Canadian Patient Safety Institute and Canadian Foundation for Healthcare Improvement.

Question 2

Healthcare Excellence Canada collaborates with many individuals and groups including…

Answer 2

Patients, families and caregivers
Healthcare providers and leaders
Healthcare quality and safety organizations
First Nations, Inuits and Métis
Governments and health regions

Question 3

What is the goal of Healthcare Excellence Canada?

Answer 3

Share innovations to improve patient safety and quality of care

Question 4

Define innovation.

Answer 4

A practice, policy or program that yields greater benefit for people compared to the status quo

Question 5

True or false. Patient safety is a key professional value and an essential component of daily practice.

Answer 5

True

Question 6

True or false. The advances in medical knowledge and technology over the decades erased safety issues.

Answer 6

False. Safety issues remain prevalent.

Question 7

True or false. The number of deaths in Canada due to avoidable medical incidents ranks as the third leading cause of death, after cancer and heart disease.

Answer 7

True :(

Question 8

Patient harm in Canadian hospitals. How often does it happen?

Answer 8

1 in 17 hospital stays

Question 9

Patient harm in Canadian hospitals. What kinds of harmful events happen?

Answer 9

Health care and medications
Infections
Procedure-related
Patient accidents

Question 10

What is the Safety Competencies Framework?

Answer 10

A framework that identifies competencies that can be adopted and adapted by diverse healthcare programs to design curricula to teach safety and quality for any sector or healthcare program.

Question 11

What are the 6 domains for safety competencies?

Answer 11

Patient safety culture
Teamwork
Communication
Safety, risk, and quality improvement
Optimized human and system factors
Recognize, respond to, and disclose patient safety issues

Question 12

Briefly describe Patient safety culture (safety competency).

Answer 12

Workplace culture : shared attitudes, values and beliefs that contribute to the social/psychological environment
Understanding our role in safety culture
Importance of ongoing collaboration and advocating for change (speaking about unsafe practices)
Set clear expectations and ‘no-blame’ system or ‘just culture’

Question 13

Briefly describe Teamwork (safety competency).

Answer 13

Collaboration
Effective conflict resolution
Value role of each member
Patient/family-centered care

Question 14

Briefly describe Communication (safety competency).

Answer 14

Effective communication to establish partnerships, build trust and obtain patient consent
Effective verbal/nonverbal communication, and effective documentation

Question 15

Briefly describe Safety, risk and quality improvement (safety competency).

Answer 15

Collect and monitor performance data to assess risk and improve outcomes :
- Detect and report safety threats
- Implement evidence informed practice
- Evaluate quality improvement interventions

Question 16

Briefly describe Optimized human and system factors (safety competency).

Answer 16

Well-being of healthcare professionals
Resource allocation/workload
Policies and procedures

Question 17

Briefly describe Recognize, respond to and disclose patient safety issues (safety competency).

Answer 17

Open, honest, and empathetic disclosure and appropriate apologies :
- Recognize, report and reflect on patient safety incident/accidents
- Recommendations for improvements
- Prevent reocurrences
- Support patients/families/team members involved in an accident/incident

Question 18

When do we report patient incidents and accidents? Who can document them? What are 2 things to include in it for prevention?

Answer 18

As soon as possible.
Employee who witnesses, discovers, or is directly involved in it (even nursing students)
Identify potential factors and interventions.

Question 19

What is the difference between incidents and accidents?

Answer 19

Incidents are events that did not reach the patient but could have caused harm
Accidents are events that reached the patient whether causing harm or not

Question 20

… is a process to inform patient/family of an accident by the physician, by verbal communication and documentation in the patient’s chart.

Answer 20

Disclosure

Question 21

Name the 3 types of Disclosure MSSS (Quebec) forms.

Answer 21

Incident/Accident Reporting Form
Analysis of Incident/Accident Form
Disclosure Form

Question 22

What is a sentinel event?

Answer 22

An event that requires in-depth analysis, because flaws in the process were identified

Question 23

What are 3 steps for patient safety?

Answer 23

Report
Disclose
Be involved

Question 24

What is the purpose for nursing documentation?

Answer 24

Professional responsibility
Helps ensure the protection of the public

Question 25

What are characteristics of nursing documentation?

Answer 25

Relevant
Concise
Complete
Organized

Question 26

What does a nursing documentation contain?

Answer 26

Observations and assessments
Evolution of the situation
Health problems identified (nursing analysis)
Care that was delivered (interventions)
Evaluation of interventions (outcomes)
Follow-up

Question 27

True or false. The patient’s chart is a legal document.

Answer 27

True

Question 28

True or false. Progress notes should focus on the the nurse’s observations.

Answer 28

False. They should focus on the nurse’s clinical decisions.

Question 29

What is used to track a nurse’s clinical decisions?

Answer 29

Therapeutic Nursing Plan

Question 30

Name the 3 reserved activities regarding clinical assessment (Nurses Act).

Answer 30

Assessment
Clinical monitoring (including monitoring and adjusting the TNP)
Follow-up

Question 31

Can nursing students alter the therapeutic nursing plan?

Answer 31

No

Question 32

Do we have to create a therapeutic nursing plan for each patient?

Answer 32

We must do one for each patient, except for those we see just once

Question 33

True or false. You don’t need to explain your adjustments in a therapeutic nursing plan.

Answer 33

False

Question 34

How would you determine a priority problem or need?

Answer 34

Requires a particular clinical follow-up
Affects the clinical follow-up
Makes a significant clinical change on the clinical follow-up

Question 35

True or false. A priority problem or need can only be a new problem or need that arose during an episode of care.

Answer 35

False. It can be the deterioration of a previously noted problem.

Question 36

True or false. The client’s priority problems and needs can be determined by anyone taking care of the client.

Answer 36

False. They are determined on the basis of the nurse’s assessment.

Question 37

The nursing directives contain…, and each directive must be linked to…

Answer 37

Crucial indications (interventions)
A priority problem or need stated in the TNP

Question 38

True or false. The TNP is a separate documentation tool that is part of a client’s chart.

Answer 38

True

Question 39

True or false. The TNP contains routine care.

Answer 39

False. It contains only the priority health problems and needs and the nursing directives identified to address them.

Question 40

What is important to consider when delegating a task?

Answer 40

Make sure they have the legal authority, knowledge and skills to perform a task

Question 41

Do the PABs have access to the clients’ files?

Answer 41

Nope

Question 42

How can student nurses contribute to a patient’s therapeutic nursing plan?

Answer 42

By communicating with nurses caring for patient their findings, recommendations and rationales for potential changes/additions to the TNP (priority or new problems)