Safety and Quality Flashcards
What is safety
Minimizes the risk of harm to the patient and providers through both system effectiveness and individual performance
What is Quality Improvement (QI)
Use data to monitor the outcomes of patient care processes ad uses improvement methods to design and test changes to continuously improve the quality and safety of health care system
What is IOM
Institute of Medicine
What is the definition of IOM
The prevention of harm to patients
What is the definition of WHO
Prevention of errors and adverse effects to
patients that are associated with healthcare
How many people die in the US due to medical errors
98,000 people
What is a Medical Error
the failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim
What is a Medical
a patient safety event (not primarily related to the natural
the course of the patient’s illness or underlying condition) that reaches a patient
and results in any of the following:
* Death
* Permanent harm (serious physical or psychological injury)
* Severe, temporary harm and intervention required to sustain life
What is the common Errors
Medication errors
* Improper transfusions
* Too much oxygen for premature
babies
* Health-care associated infections
* Central-line infections
* Falls
* Surgical errors
* Pharmacy errors
* Lab errors
* Treatment errors
* Birth injuries
* Restraint-related injuries or death
* Burns
* Pressure ulcers
* Mistaken patient identities
What is the Joint Commission and what do they do
An independent, not-for-profit organization
* Accredits and certifies nearly 21,000 health care organizations and
programs in the US
* Joint Commission accreditation
and certification is recognized
nationwide as a symbol of
quality that reflects an
organization’s commitment to
meeting certain performance
standards
What are national patient safety goals
first set of NPSGs put into effect January 1,
2003
* Help accredited organizations address specific areas of concern in regard to patient
safety
* Purpose: improve patient safety
* Goals focused on problems in health care safety and how to solve them* Goals specific to setting:
* Hospitals
* Ambulatory Health Care
* Behavioral Health Care
* Critical Access Hospital
* Home care
What are the hospital NPSG’s
identify patients correctly
* Improve staff communication
* Use medicines safely
* Use alarms safely
* Prevent infection
* Identify patient safety risks
* Prevent mistakes in surgery
What are the response for medical error
Serious adverse events require an immediate investigation and
response
* Accredited organizations are expected to use a “thorough and
credible Root Cause Analysis (RCA) and action plan”
* Organizations should disclose the error and apologize to the patient,
report the event, and waive all costs associated with the event
* Goals
* Protect the patient
* Improve systems
* Prevent further harm
How do nurses play a vital role in ensuring patients’ safety by
monitoring patients for clinical deterioration
* detecting errors and near misses
* understanding care processes and weaknesses inherent in some systems
* coordinating high-quality care through collaboration with physicians, pharmacists, families,
and all other members of the health care team
What are the key features of culture of Safety: A Commitment to
Safety at All Levels
Key Features:
* acknowledgment of the high-risk nature of an organization’s activities and the
determination to achieve consistently safe operations
* a blame-free environment where individuals are able to report errors or near
misses without fear of reprimand or punishment
* encouragement of collaboration across ranks and disciplines to seek solutions to
patient safety problems
* organizational commitment of resources to address safety concerns
