Week 7: Quality Improvement and Patient Safety

Question 1

Measurable items that reflect that quality of care provided and demonstrate the degree to which desired outcomes are accomplished`

Answer 1

Clinical Indicators

Question 2

An unintended typically adverse patient acquired condition that occurs from receiving care in a hospital

Answer 2

Hospital Acquired infection

Question 3

The differences in how work steps might be accomplished and/or the variables that may affect each step of the process

Answer 3

Process Variation

Question 4

A series of linked step necessary to accomplish work

Answer 4

Process

Question 5

Framework for action to systematically make change that lead to measurable improvements in healthcare services for patients, staff, and organizations

Answer 5

Quality Improvement

Question 6

Method of problem-solving that attempts to identify how and why an event occurs

Answer 6

Root Cause Analysis

Question 7

A patient safety event that reaches a patient and results in death permanent harm or severe temporary harm requires intervention to sustain LIFE

Answer 7

Sentinel Event

Question 8

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

Answer 8

Standardization

Question 9

A non-profit organization with a mission of advancing and disseminating scientific knowledge to improve human health

Answer 9

Academy of Medicine

Question 10

A national agency that conducts surveys of inpatient and ambulatory healthcare facilities and verifies their compliance with established quality standards

Answer 10

The Joint Commission (TJC)

Question 11

What is QSENs

Answer 11

Knowledge, Skills and attitudes

Question 12

what is QSEN knowledge

Answer 12

Examine human factors and other basic safety design principles as well as commonly used unsafe practices

Question 13

QSEN skills

Answer 13

Demonstrate effective use of technology and standardization practices that support safety and quality

Question 14

QSEN vaules

Answer 14

Value the contributions of standardization/reliability to safety

Question 15

On average, patients are subjected to at least ___________each day with high costs to patients, families, health care professionals, hospitals, and insurance companies

Answer 15

one medication error

Question 16

what is the model for improvement?

Answer 16

• plan
• implement
• evaulate
• improve

Question 17

what is the PDSA method

Answer 17

plan
do
study
act

Question 18

what is evidence-based practice?

Answer 18

is using research in clinical practice involving the client to give quality care and use best practice.

1. patient’s values
2. expert option
3. evidence-based research

Question 19

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!

Answer 19

Shared Governance

Question 20

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)

Answer 20

clinical indicator

Question 21

what is the Nurse Sensitive Clinical Indicators

Answer 21

Compare institution at local, regional and national level

Link outcomes to nurse staffing

Question 22

example of regualtory agencies

Answer 22

The joint commission states accreditor, voluntary groups

Question 23

______________ 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

Answer 23

The joint commission (TJC)

Question 24

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.

Answer 24

Standards of Compliance

Question 25

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)

Answer 25

adverse events and sentinel events

Question 26

examples of sentienal events are

Answer 26

Accuracy of patient identification
Communicating critical results
Reducing Alarm fatigue
Medication Safety 
Suicide risk
Infections
Surgical events: timeouts and checklists

Question 27

the model for errors is called the

Answer 27

swiss chesse model

Question 28

_______________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.

Answer 28

Risk management

Question 29

Nurse’s role also includes reporting not only real errors, but also “_________” errors that are caught before they reach a patient

Answer 29

near miss

Question 30

what safety events should be reported?

Answer 30

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

Question 31

Hwo do you report saftey issues?

Answer 31

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

Question 32

___________ are the documentation of errors and the factors leading up to and including when an error occurs in the health care system.

Answer 32

Incident reports

Question 33

what is Just Culture?

Answer 33

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.

Question 34

Never events

Answer 34

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

Question 35

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.

Answer 35

sentinel event

Question 36

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.

Answer 36

root cause analysis

Question 37

what are standarized preactices to help prevent error?

Answer 37

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

Question 38

There are clinical ________ to help outline the optimal sequencing and timing of clinical interventions for diagnosis or procedure

Answer 38

Pathways