Quality Improvement and Incident Reports Flashcards
Quality improvement
The combined and unceasing efforts of everyone - healthcare professionals, patients and their families, researchers, payers, planners and educators - to make the changes that will lead to better pt outcomes, better system performance, and better professional development
Why quality improvement?
improve quality of product system processes or method, prevent errors, propose solutions, interprofessional team, better outcomes, make right thing easy, culture of improvement in everything
How do we do quality improvement?
study data, contributing factors, propose solutions, set outcomes, assess via interprofessional team
incident reports
hospital documentation that DOES NOT go into pt chart - used for errors/near misses. out of ordinary/potential to cause harm - pts/employees/visitors
if something is pt specific
it does go into the chart
What are incident reports used for?
see where errors are occurring, what is causing them, how can they be prevented. used to id risks not disciplinary action, improve treatment by id high risk patterns/prevent future problems
Info contained in incident report
name of person/witnesses, FACTUAL account of incident/assessment, care provided, equipment involved/who notified, pts response to care, date/time/place of incident, report all even if no adverse reaction, documentation by provider of medical examination of person involved, document what pt or family says about their role (ex: I thought I could make it to the bathroom). medical record is pt focused, don’t mention incident report. if you discovered the incident fill out report before you leave (be thorough)
What needs an incident report?
fall, med error, incorrect implementation of prescribed treatment, loss of pt belongings (ex: dentures, hearing aids), injury to pt/visitor/staff, unsafe staffing (feel like can’t take care of b/c not enough), lack of availability of essential pt care supplies, inadequate response to emergency situation (rapid response team)
Priority with incident reports
communication soothes anger/prevents lawsuits. assess for injury, institute immediate care measure to decrease further injury
Goal of incident reports
prevent incident from happening again
Does a walking patient stubbing toe on an IV pole require incident report?
yes
Does finding a patient sitting on the floor with no injuries require an incident report?
yes
Does finding a patient on the floor with a laceration on their head require an incident report?
yes
Does nicking your thumb with a clean needle while preparing to draw heparin require an incident report?
no
Does medical device malfunction, pt staff or visitors injured or involved in a situation with potential injury require an incident report?
yes
