Safety & Quality Flashcards
What is quality care?
Good care.
What does TJC stand for?
The Joint Commission (regulatory agency)-They have national patient safety goals.
What does safety mean?
Freedom from accidental injury & also fundamental. You keep them safe! It is very important and can cause an issue.
*100% is safe!
What type of hazard is a fall?
Falls are one of the biggest safety hazards in the hospital.
*A lot of meds can cause dizziness and make you drowsy.
What is a work around?
This is how you do it, but this is how I am going to do it.
What is are operational systems?
Ex. Anderson Hospital has policies & procedures in place & tracking-keeps people responsible for their actions
What is System Processing?
Trying to minimize incidence of errors to keep pt. safe for ex. certain arm bands for kidnapping of infants & it beeps when close to door. Also want to avoid injuries to patients while caring for them & follow the rules.
How does EHR keep patients safe?
Before giving medications, the mar may alert you to go look at labs results to be sure you are not giving to much of the medication before you try to give another dose.
Areas of safety concerns in the hospital?
*Surgical -Not being sterile or not having the right pt./Not doing right thing ( Removing wrong body part), Leaving instruments/sponges in pt. Gases can be flammable or Cautery when using it.
-Feelings getting in the way of dealing with pt. care-these are distractions & not being able to get things done
-Food safety, administration dosages & not charting medications, treatment, & diagnoses properly., side rails
-Be knowledgeable of precautions & ordered appropriately & following directions
-High fall risk (sign outside door)/leave door open/HIPPA Violation if chart open & safety concern because someone can easily chart
-Toileting/side rails down, malfunctioning equipment-tagged by biomed until fixed
-Aggressive pt. (sundowning)
What is the scope of practice for safety & quality?
To go from no error to death-Trying to keep all patients safe from injury. There are different types of errors listed below.
*We want good safe and quality care for our patients.
What happens if an error is made?
Errors should be reported& sent to a quality risk management department to review what happened to see why the error was made.
-There should be a system put into place or protocols to prevent this error from happening again.
*Busy, not enough staff, & not having the equipment can cause errors.
*The errors are reported, & they should be able to come up with ways to prevent these things from happening.
What is an adverse event?
Results in unattended harm (Med errors (#1 error), allergic/anaphylactic response, Falls, Burn (heating pads), & Infection
What is a near miss?
(3 levels of errors that almost happened but you caught the error)-Medication related (seen most-hydroxyzine/Hydroline), & wrong dosage-Need to report/learn from it & separate the drugs(improve processes)
What are sentinel events or a Nevel event?
Should never happen-Reported national to Joint Commission that can result in some serious or death-Like Medication errors (giving potassium to fast through IV)
*Surgery-wrong limb taken off or surgical instrument left in pt.
*Drop baby or Infant abduction or something to cause the baby to die & fall result in serious injury or death
*Mismatched blood (infected blood)
*Losing a pt. (like a suicide pt). at risk
*Severe pressure ulcer injury or CAUTI
What is a root cause analysis?
What really happened? (Was there not enough staff or wrong procedures)
What are some types of errors?
*Diagnostic-Any error involving some type of testing (mislabeling specimen, follow up with test (High level of electrolyte balance like 6 of Potassium)
*Treatment Error-Delay of treatment (Nurse didn’t do her job)
*Preventative Error-Failure to provide prophylactically care (Access pt. for blood clots) could lead to sentinel event
*Communication Failure-Lack of good communication/Can lead to adverse event/sentinel event
Patient Transfer/Handoff report to another unit/Beside Reports are bad with communication.
What are the placement of errors (What caused the error)?
*Active or Sharp Errors-(Pertaining to one person) Provider or nurse
*Latent (dull) Error-Flaw in the system (flaw in how call schedule with providers (wrong provider called) or the way medications are given
*Always access pt. first if an error is made. Then if problem with amount(twice dosage) of BP Medication-check another BP, Contact provider, Watch BP, Let charge nurse/supervisor, & chart. Take any orders given & do incident report in timely manner.
*Incident Report-Documentation of errors sent to error department/Very detailed of what happened (TIME,DATE, PT. & WHAT HAPPENED) & not part of Electronic Record but with facts in Electronic Record)
-Goal to change processes and look for opportunities to do better
What is the most dangerous phrase in healthcare?
“We’ve always done it this way.”
Attributes & Criteria-Knowledge, Skills, & Attitudes
*Knowledgeable of proper techniques, procedures, protocols (In service, Readings) benefits, & limitations to keep pt. safe. Keeps you away from taking care of your pt. (EHR.)
*Skills-(Inservice, checked off on monitors, IV pumps)
*Attitude for attribute of safety-Confident & caring, & compassionate, professional & collaborative attitude
What is culture of safety?
Within organization begins from top to bottom (CEOs down to janitors)- They are on the same page related to safety. Management has money, enough staff, & things you need to take care of pts. & Communication of collaboration that is open & error reporting systems
-Open communication/error reporting systems/ (error reducing methods)
- “Just” Culture- Near Miss-Should never be afraid that you will get in trouble. Culture within an organization that does not penalize you.
*Be very transparent when making errors. Tell the error because it can cause serious injury/death. Never be afraid reporting injury and be accountable.
*You want to feel like you are accountable and able to admit you mistakes and hopefully there is a system in place to fix the flaw.
What happens with quality? Errors with Abbreviations
There can’t be if a lot of infections or errors?
*Never use 10u write 10 units, Write International Unit
*Don’t use QD or qd in no form- Write “daily” or q6h, don’t use qod instead write “every other day”
*4.0 has trailing zero & can be mistaken for 40. 4.1 is ok. Just put 4 if 4.0.
*Lack of leading zero is .7 has to have a zero and be 0.7.
*Don’t use MSO4 AND mgSO4. Instead use “morphine sulfate” or “magnesium sulfate” & Look at other abbreviations
*Look & see what Hospital National Patient Safety Goals are, and things to reduce errors from happening.
Why do falls happen?
*Unintentional inadvertent accident (can be small/big)
-Could be due to short staffage (Not enough people rounding)
*Forgetting to put up siderail, they are sick, need to go to bathroom, wrong foot wear, cognitive impairment, environment (torn rugs)
*Polypharmacy-Drug interactions between mixing up med, or new BP meds-dizziness, BP drops or hypotension occurs
*What is Gait/Parkinson’s shuffle-likely to fall/Can trip over cord or IV Pole
*Incontinent-Leaking urine/Sign most likely yellow indicating fall risk
*Know facility policy (Look over Fall prevention measures-Skill 27.1 in Fundamentals book
-Having quality care is having good care
*Males fall more than females
*High risk pt. should be near nurse’s station or have someone really close to them (One on one)
How can you prevent falls from happening?
*Identify pt. as fall risk, place a fall mat, place a sign on door for high fall risk, Side rails up, bed alarms, pads in bed (weight shifts to alert staff of movement), & lots of pt. education
*Environment-You want some light & not in complete dark, place wet floor sign when floor is wet, keep pathway clear for pt., use grippy socks, place call bell within reach, & make sure the bed is locked in lowest position
*Can put up 2 or 3 siderails up /4 is used as a restraint & Cane should be within reach & on side of bed
*Elimination schedules (One of the best ways to prevent falls is purposeful rounding-Every hour or two hours to see if they need to potty if on high risk for falls)
Fall Assessment: Morse Scale
*The higher the score the worse it is.
-Risk assessment (Done on admission), or change in level of care or condition, once a shift, and if they fall/Want to prevent a fall
-Can’t delegate/Can delegate the fall prevention-Help to bathroom, educate, use socks
