Safety and Security Flashcards
what is QSEN?
quality and safety of education of nurses
what is IOM?
institute of medicine
what is TJC?
the joint commission
what are the 3 failures?
to recognize: doesn’t see anything wrong
to rescue: sees something wrong but does nothing
to plan: what to do during infrequent events (CPR, fire drills)
what are med mistakes often due to?
misreading orders
course specific preparations?
skills check offs
simulation grading
med calc quizzes
what is code pink?
baby missing
what are the QSEN competencies?
patient centered care
teamwork/collaboration
evidence based practice
quality improvement
safety
informatics
QSEN defines safety as “minimizing risk of harm to patients and providers through”
both system effectiveness and individual performance
what is individual performance?
controlling yourself
*don’t talk or think about other things
what is NPSG?
national patient safety goals
patient safety goal to correctly identify patients?
checking ID bands
*name and DOB
patient safety to improve staff communications?
knowing and following up on orders
*SBAR, correct reporting
patient safety goals that help safe medication use?
labelling meds
med reconciliation: missing info
4 checks
patient safety goals for alarm safety?
answer alarms
“alarm fatigue”: figure out problem and fix it, don’t silence it
safety goal to prevent infection?
hand hygiene
what is fire safety? “RACE”
R: rescue: anyone in immediate danger
A: activate: fire code and notify person
C: confine: the fire by closing doors and windows
E: evacuate: patients and others to safe area
what is a medication error?
breakdown or failure at any point in the med use process
how many are injured each year from med errors?
1.5 million injured
440,000 die
*$3 billion annually
what are the types of medication errors?
omission
commission
communication
what is omission?
something missed or left out
*not prescribed, dispensed, administered, or taken
what is commission?
doing something wrong, making a mistake
*wrong drug/dose prescribed, dispensed, administered
*wrong patient, timing, route
*allergic or drug reaction
what is the most common type of drug error made by students?
omission
what are the contributing factors to student med errors?
inexperience and distraction
med pass communication error example?
duality of patient assignments
-you think nurse is passing med, nurse think you are, no meds passed
-nurse thinks she is passing med, you think you are passing med, 2x meds given
NURSE NEEDS TO KNOW WHAT WHEN AND WHO
what are insulin errors?
selecting wrong insulin
wrong dose/wrong patient
med error examples?
-administering on hold or discontinued meds
-not monitoring labs or VS
-preparing oral meds in parenteral syringes and giving IV
what color are oral syringes?
brown
what color are parenteral syringes?
clear
parenteral vs enteral?
parenteral: into vein delivered straight to bloodstream
enteral: into stomach
what is one of the major never events?
falls
what ID band is for falls?
yellow
*predicting is important in preventing
what gender is more at risk for falls?
females
at what age does fall risk increase?
65+
what are three things that increase risk for fatal falls?
surviving stroke
surviving heart attack
taking multiple meds
if you are 75 years and older and fall you are ___-___x more likely to be admitted to a end care facility
4-5
fall risk factors?
> 65
fall history
cognitive impairment
altered gait - using cane/walker
meds
incontinence
unsafe environment
sensory deficits - glasses/hearing aids
orthostatic hypotension
depression
assistive devices
confusion/disorientation
new environment
fall prevention interventions
complete assessments
frequent rounding
fall precautions
toiletting assistance Q2
no slip socks
bed in low and alarms on
personal items in reach
call light in reach/answer promptly
when do most people fall?
going to toilet
low risk score?
0-44
medium risk score?
45-75
high risk score?
76-100
what is a restraint?
any involuntary method chemical or physical of restricting an individual’s freedom of movement, physical activity, or normal access to body
when should restraints be employed?
only when no other viable option is available
restraints don’t _____, usually ______
don’t protect, usually hurt
recommended use of restraints? (when to use)
-ensure immediate safety of patients and staff
-prevent interruption of therapy
-prevent confused or combative patient from removing life support equipment or unsafe attempts at mobility
posey vest used?
to prevent patients from injuring themselves by falling out of bed/chair
mitts use?
to prevent pulling/picking at IVs
wrist restraints use?
prevent interference with care
upper arm restraint?
to stop bending of elbow
four side rails up considered?
restraints
*cannot use
hazards of restraints/side rails?
impaired circulation
altered skin integrity
altered nutrition/hydration
aspiration/difficulty breathing
incontinence
increased possibility of injury from falls
depression/anxiety
death
does routine restraint use lower risk of falls?
no
how often do we check non violent restraints?
Q2
Q4 for food
how often do we check violent restraints?
every 15 mins
Q2 for ROM/fluid/elimination
Q4 for food
should safety event reports be put in EMR documentation?
no
