Patient Safety and Documentation Flashcards
Healthcare Excellence Canada brings together…
Canadian Patient Safety Institute and Canadian Foundation for Healthcare Improvement.
Healthcare Excellence Canada collaborates with many individuals and groups including…
Patients, families and caregivers
Healthcare providers and leaders
Healthcare quality and safety organizations
First Nations, Inuits and Métis
Governments and health regions
What is the goal of Healthcare Excellence Canada?
Share innovations to improve patient safety and quality of care
Define innovation.
A practice, policy or program that yields greater benefit for people compared to the status quo
True or false. Patient safety is a key professional value and an essential component of daily practice.
True
True or false. The advances in medical knowledge and technology over the decades erased safety issues.
False. Safety issues remain prevalent.
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.
True :(
Patient harm in Canadian hospitals. How often does it happen?
1 in 17 hospital stays
Patient harm in Canadian hospitals. What kinds of harmful events happen?
Health care and medications
Infections
Procedure-related
Patient accidents
What is the Safety Competencies Framework?
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.
What are the 6 domains for safety competencies?
Patient safety culture
Teamwork
Communication
Safety, risk, and quality improvement
Optimized human and system factors
Recognize, respond to, and disclose patient safety issues
Briefly describe Patient safety culture (safety competency).
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’
Briefly describe Teamwork (safety competency).
Collaboration
Effective conflict resolution
Value role of each member
Patient/family-centered care
Briefly describe Communication (safety competency).
Effective communication to establish partnerships, build trust and obtain patient consent
Effective verbal/nonverbal communication, and effective documentation
Briefly describe Safety, risk and quality improvement (safety competency).
Collect and monitor performance data to assess risk and improve outcomes :
- Detect and report safety threats
- Implement evidence informed practice
- Evaluate quality improvement interventions
Briefly describe Optimized human and system factors (safety competency).
Well-being of healthcare professionals
Resource allocation/workload
Policies and procedures
Briefly describe Recognize, respond to and disclose patient safety issues (safety competency).
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
When do we report patient incidents and accidents? Who can document them? What are 2 things to include in it for prevention?
As soon as possible.
Employee who witnesses, discovers, or is directly involved in it (even nursing students)
Identify potential factors and interventions.
What is the difference between incidents and accidents?
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
… is a process to inform patient/family of an accident by the physician, by verbal communication and documentation in the patient’s chart.
Disclosure
Name the 3 types of Disclosure MSSS (Quebec) forms.
Incident/Accident Reporting Form
Analysis of Incident/Accident Form
Disclosure Form
What is a sentinel event?
An event that requires in-depth analysis, because flaws in the process were identified
What are 3 steps for patient safety?
Report
Disclose
Be involved
What is the purpose for nursing documentation?
Professional responsibility
Helps ensure the protection of the public
What are characteristics of nursing documentation?
Relevant
Concise
Complete
Organized
What does a nursing documentation contain?
Observations and assessments
Evolution of the situation
Health problems identified (nursing analysis)
Care that was delivered (interventions)
Evaluation of interventions (outcomes)
Follow-up
True or false. The patient’s chart is a legal document.
True
True or false. Progress notes should focus on the the nurse’s observations.
False. They should focus on the nurse’s clinical decisions.
What is used to track a nurse’s clinical decisions?
Therapeutic Nursing Plan
Name the 3 reserved activities regarding clinical assessment (Nurses Act).
Assessment
Clinical monitoring (including monitoring and adjusting the TNP)
Follow-up
Can nursing students alter the therapeutic nursing plan?
No
Do we have to create a therapeutic nursing plan for each patient?
We must do one for each patient, except for those we see just once
True or false. You don’t need to explain your adjustments in a therapeutic nursing plan.
False
How would you determine a priority problem or need?
Requires a particular clinical follow-up
Affects the clinical follow-up
Makes a significant clinical change on the clinical follow-up
True or false. A priority problem or need can only be a new problem or need that arose during an episode of care.
False. It can be the deterioration of a previously noted problem.
True or false. The client’s priority problems and needs can be determined by anyone taking care of the client.
False. They are determined on the basis of the nurse’s assessment.
The nursing directives contain…, and each directive must be linked to…
Crucial indications (interventions)
A priority problem or need stated in the TNP
True or false. The TNP is a separate documentation tool that is part of a client’s chart.
True
True or false. The TNP contains routine care.
False. It contains only the priority health problems and needs and the nursing directives identified to address them.
What is important to consider when delegating a task?
Make sure they have the legal authority, knowledge and skills to perform a task
Do the PABs have access to the clients’ files?
Nope
How can student nurses contribute to a patient’s therapeutic nursing plan?
By communicating with nurses caring for patient their findings, recommendations and rationales for potential changes/additions to the TNP (priority or new problems)
