Nurses Role in Quality, Safety, and Assessment

Vocabulary practice flashcards created from lecture notes covering quality, safety, nursing assessment, national safety goals, and risk assessment scales.

Quality

Excellence or superiority, often viewed as a continuum in healthcare.

Safety

The avoidance or prevention of adverse outcomes for patients, or the state of being free from harm or danger. Reduces stress, promotes general health, and allows people to meet their other basic needs.

Root Cause Analysis

A process used to determine the underlying cause of an error or safety issue.

Near Misses

Event or situation that could have resulted in an adverse event but did not, either by chance or through timely intervention.

Just Culture

A framework that holds individuals and organizations accountable for maintaining safety.

Sentinel Events

Unanticipated events in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.

Never Events

Errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, indicating a real problem in the safety and credibility of a healthcare facility.

Institute for Healthcare Improvement (IHI)

An independent non-profit organization focused on improving healthcare quality and safety worldwide.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

A standardized survey instrument and data collection methodology for measuring patients' perspectives of hospital care.

The Joint Commission

An independent organization that accredits and certifies healthcare organizations in the United States, ensuring they meet specific performance standards and improve quality and safety.

Centers for Medicare and Medicaid Services (CMS)

A federal agency that measures quality care and patient safety in relation to hospital reimbursement practices.

The QSEN Institute

A resource organization dedicated to improving nursing education by integrating quality and safety competencies into the curriculum.

Occupational Safety and Health Administration (OSHA)

A federal agency within the U.S. Department of Labor that sets and enforces safety guidelines for healthcare workers.

State Health Agencies

Government organizations responsible for public health oversight, regulation, and safety within states, focusing on quality care and disease prevention.

Joint Commission Hospital National Patient Safety Goals

A set of specific guidelines established by the Joint Commission to enhance patient safety in healthcare organizations and improve the quality of care delivered.

NPSG.01.01.01

National Patient Safety Goal requiring the use of at least two ways to identify patients (e.g., name and date of birth) to ensure correct medicine and treatment.

NPSG.02.03.01

National Patient Safety Goal focused on improving staff communication by getting important test results to the right staff person on time.

NPSG.03.04.01

National Patient Safety Goal requiring labeling of medicines that are not labeled (e.g., in syringes, cups, basins) before a procedure in the setup area.

NPSG.03.05.01

National Patient Safety Goal requiring extra care with patients who take medicines to thin their blood.

NPSG.03.06.01

National Patient Safety Goal for recording and passing along correct medication information, comparing current medications to new ones, and giving written information to the patient.

NPSG.06.01.01

National Patient Safety Goal to make improvements ensuring alarms on medical equipment are heard and responded to on time.

NPSG.07.01.01

National Patient Safety Goal requiring hand cleaning guidelines from the CDC or WHO to prevent infection.

NPSG.15.01.01

National Patient Safety Goal to identify patient safety risks by reducing the risk for suicide.

UP.01.01.01

Universal Protocol goal to make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body.

UP.01.02.01

Universal Protocol goal requiring marking the correct place on the patient's body where the surgery is to be done.

UP.01.03.01

Universal Protocol goal requiring a pause before surgery to make sure that a mistake is not being made.

Competencies for Nursing

Includes patient-centered care, teamwork/collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics.

Patient-centered care

Recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.

Teamwork and collaboration

Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

Evidence-Based Practice (EBP)

Integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.

Quality Improvement (QI)

Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.

Safety (QSEN Competency)

Minimizing risk of harm to patients and providers through both system effectiveness and individual performance.

Informatics

Using information and technology to communicate, manage knowledge, mitigate error, and support decision-making.

Injury

A particular form or instance of harm that has a recognizable pattern of occurrence.

Nurse Responsibility

Nurses are responsible for assessing the patient, their equipment, and the environment; and for providing safe care that includes injury control and maintaining a safe environment.

Normal Pattern Identification

An assessment phase focused on gathering information regarding current safety practices or plans for management of hazards.

Risk Identification

An assessment phase evaluating recent changes in cognition, perception, sensation, activity, occupation, home environment, lifestyle, habits, and level of safety practice knowledge.

Dysfunction Identification

An assessment component present when a patient reports a serious, preventable injury, a recent change in ability to participate safely in ADLs (Activities of Daily Living), or performs unsafe behavior.

Physical Assessment (Safety Focus)

Physical examination focusing on specific body systems relevant to safety: neurologic and sensory, cardiovascular, respiratory, musculoskeletal, and integument.

Diagnostic Tests and Procedures (Safety Focus)

Evaluations used to determine a person's health status by assessing for medical conditions that place them at risk for injury.

Safety Considerations (Adults)

Safety habits may be disregarded through disregard of judgment, overconfidence, or ignorance. Alcohol consumption increases risk of injury. Motor vehicles are a major cause of death; seatbelt use is imperative.

Safety Considerations (Older Adult)

Older adults may have impaired sensory, motor, cognitive function. Decreased thermoregulatory ability increases risk of heat stroke or hypothermia. Medications for chronic condition may cause dizziness or orthostatic hypotension, increasing fall risk.

Morse Fall Scale

A fall assessment tool determining risk based on factors including fall history, secondary diagnosis, ambulatory aids, IV access, gait, and mental status.

Hendrich II Fall Risk Model

A risk model scoring factors such as confusion/disorientation, depression, altered elimination, dizziness, male gender, specific medications, and the Get Up & Go Test.

Mini-Mental State Examination (MMSE)

A screening tool assessing cognitive function across categories including orientation, registration, attention and calculation, recall, and language.

Braden Scale

A clinical assessment tool predicting pressure sore risk based on sensory perception, moisture, activity, mobility, nutrition, and friction & shear.

Glasgow Coma Scale

A clinical scale evaluating level of consciousness using three categories: Best eye response (E), Best verbal response (V), and Best motor response (M).

Factors Affecting Safety Model

A conceptual framework identifying main safety influences: Patient (physiologic & psychosocial), Environment specific, Equipment patient uses/requires, and Others.