Week 7: Quality Improvement and Patient Safety Flashcards
Measurable items that reflect that quality of care provided and demonstrate the degree to which desired outcomes are accomplished`
Clinical Indicators
An unintended typically adverse patient acquired condition that occurs from receiving care in a hospital
Hospital Acquired infection
The differences in how work steps might be accomplished and/or the variables that may affect each step of the process
Process Variation
A series of linked step necessary to accomplish work
Process
Framework for action to systematically make change that lead to measurable improvements in healthcare services for patients, staff, and organizations
Quality Improvement
Method of problem-solving that attempts to identify how and why an event occurs
Root Cause Analysis
A patient safety event that reaches a patient and results in death permanent harm or severe temporary harm requires intervention to sustain LIFE
Sentinel Event
Approach to process improvement that involves developing and adhering to best-known methods and repeating key tasks, in the same way, is found to create exceptional and efficient services
Standardization
A non-profit organization with a mission of advancing and disseminating scientific knowledge to improve human health
Academy of Medicine
A national agency that conducts surveys of inpatient and ambulatory healthcare facilities and verifies their compliance with established quality standards
The Joint Commission (TJC)
What is QSENs
Knowledge, Skills and attitudes
what is QSEN knowledge
Examine human factors and other basic safety design principles as well as commonly used unsafe practices
QSEN skills
Demonstrate effective use of technology and standardization practices that support safety and quality
QSEN vaules
Value the contributions of standardization/reliability to safety
On average, patients are subjected to at least ___________each day with high costs to patients, families, health care professionals, hospitals, and insurance companies
one medication error
what is the model for improvement?
- plan
- implement
- evaulate
- improve
what is the PDSA method
plan
do
study
act
what is evidence-based practice?
is using research in clinical practice involving the client to give quality care and use best practice.
- patient’s values
- expert option
- evidence-based research
In a __________model, all staff nurses are actively engaged in quality improvement
Identifying areas needing improvement
Active in auditing and measuring indicators on your unit daily/weekly/monthly etc.
Collaborating with interdisciplinary healthcare team in process improvements
Serving on hospital QI research projects
Transparency: read emails with information sent to you!
Shared Governance
Foundation for quality monitoring and evaluation
Measurable
Used as an assessment of clinical care to identify areas in which quality improvement issues may be present
Help to identify the goals of quality improvement
Ex. We are at 40%, and need to get to 100% (insert an indicator here, such as hand hygiene)
clinical indicator
what is the Nurse Sensitive Clinical Indicators
Compare institution at local, regional and national level
Link outcomes to nurse staffing
example of regualtory agencies
The joint commission states accreditor, voluntary groups
______________ Evolved as an impartial national organization that accredits hospitals and other health care facilities based on their safety performance, policy, procedures, practice, and outcomes.
used by over 22,000 health care institutions and programs
The joint commission (TJC)
Since most health care organizations embrace and routinely practice these goals, they are cataloged into a register of adopted “_________” that must be met on a consistent basis.
Standards of Compliance
In contrast to standards of compliance, newly created and approved National Safety Goals are endorsed every year based on the ___________and _________ that have trended nationally in health care facilities. (Review 2021)
adverse events and sentinel events
examples of sentienal events are
Accuracy of patient identification Communicating critical results Reducing Alarm fatigue Medication Safety Suicide risk Infections Surgical events: timeouts and checklists
the model for errors is called the
swiss chesse model
_______________is the process of reducing the risk of errors by understanding the causes and beginning to change the culture with communication and collaboration of individual staff and management.
Risk management
Nurse’s role also includes reporting not only real errors, but also “_________” errors that are caught before they reach a patient
near miss
what safety events should be reported?
Client safety event that occurred with or without injury but had potential to harm
Sentinel event/ never event: serious harm
Near Misses
Equipment/Supply issues that slowed or interfered with patient care
Hwo do you report saftey issues?
Incident Reports
Alert Manager who may alert risk manager if needed
Sentinel events: MUST be reported to The Joint Commission
Whistle-blow if not reported by administration
___________ are the documentation of errors and the factors leading up to and including when an error occurs in the health care system.
Incident reports
what is Just Culture?
The concept promotes a process where mistakes or errors do not result in automatic punishment, but rather a process to uncover the source of the error.
Never events
are medical errors that are identifiable, preventable, and have potential for seiours risk to clients. The occurrence of a never event reveals a problem in safety and credibility of a health care facility
The Joint Commission defines a _________ as an incident of unsafe practice that resulted in extreme harm, short-term harm, permanent disability, or death of a client.
sentinel event
A _________, also called an RCA, follows the Joint Commission’s directive to investigate an incident to determine what happened and how to prevent it from happening again.
root cause analysis
what are standarized preactices to help prevent error?
checklist for:
- surgical timeouts
- urinary catheter insertion
sterile cockpit: do not interrupt when clinicians eterning orders or nurse is calculating a preparing medications
+
Quiet xones, flags on computers, duct tape around med stations
There are clinical ________ to help outline the optimal sequencing and timing of clinical interventions for diagnosis or procedure
Pathways
