Quality Care and Patient Safety

Patient Safety

Freedom from injury.

Patient safety is considered what type of human need?

Basic human need.

Patient safety underlies what?

All nursing care.

Patient safety is a major responsibility of whom?

Nurses.

Focus of safety assessments (individual)

Encourage clients to speak up; encourage active participation in healthcare; promote error prevention.

Focus of safety assessments (environment)

Use risk assessment tools; evaluate clients and surroundings for safety.

Who should specific risk factors and plan of care be communicated to?

Patient; family; staff.

Examples of specific risk factors

Allergies; fall risk; extremity that cannot be used for blood pressure measurements.

National Academy of Medicine was formerly known as what?

Institute of Medicine (IOM).

National Academy of Medicine established

1970.

National Academy of Medicine type of organization

Independent nonprofit organization.

National Academy of Medicine is the health arm of what organization?

National Academy of Sciences.

National Academy of Medicine provides what type of recommendations?

Evidence-based recommendations.

To Err Is Human published

1999.

To Err Is Human highlighted what?

Medical errors.

To Err Is Human estimated how many deaths per year due to medical errors?

98,000.

Crossing the Quality Chasm published

2001.

Crossing the Quality Chasm focused on what?

Improve healthcare delivery and promote innovation.

Health Professions Education: A Bridge to Quality published

2003.

Keeping Patients Safe published

2004.

Keeping Patients Safe emphasized what?

Importance of nurses in preventing errors.

Preventing Medication Errors published

2006.

Preventing Medication Errors focused on what?

Medication safety and prevention strategies.

Medical error definition

Failure of a planned action to be completed as intended OR use of an incorrect plan.

Major finding of To Err Is Human

Cost of medical errors.

Major finding of To Err Is Human

Connection between quality care and patient safety.

Major finding of To Err Is Human

Need for system-wide changes.

Major finding of To Err Is Human

Preventing, recognizing, and mitigating harm.

Major finding of To Err Is Human

Creation of National Center for Patient Safety within AHRQ.

QSEN established

2007.

QSEN funded by whom?

RWJF.

QSEN purpose

Address gaps in nursing education.

QSEN competencies

Knowledge; Skills; Attitudes (KSA).

K in KSA

Knowledge.

S in KSA

Skills.

A in KSA

Attitudes.

QSEN used for

Nursing curricula; transition to practice; continuing education; licensure; certification; accreditation.

Joint Commission abbreviation

TJC.

First National Patient Safety Goal

Identify patients correctly.

Second National Patient Safety Goal

Improve staff communication.

Third National Patient Safety Goal

Use medications safely.

Fourth National Patient Safety Goal

Use alarms safely.

Fifth National Patient Safety Goal

Prevent infection.

Sixth National Patient Safety Goal

Identify patient risks.

Seventh National Patient Safety Goal

Prevent surgical mistakes.

Eighth National Patient Safety Goal

Improve healthcare equity.

ISMP purpose

Prevent medication errors.

ISMP collects reports of what?

Near misses; medication errors; adverse drug events.

ISMP provides what?

Education.

ISMP advocates for what?

Medication safety standards.

ISMP conducts what?

Research.

AHRQ purpose

Produce evidence to make healthcare safer, higher quality, accessible, equitable, and affordable.

AHRQ created what?

TeamSTEPPS.

TeamSTEPPS will be on the exam.

True.

Four TeamSTEPPS components

Communication techniques; mutual support; leadership strategies; situation monitoring.

First TeamSTEPPS component

Communication techniques.

Second TeamSTEPPS component

Mutual support.

Third TeamSTEPPS component

Leadership strategies.

Fourth TeamSTEPPS component

Situation monitoring.

Advocacy and assertion steps

Make an opening; state concern; state problem; offer solution; reach agreement.

Purpose of call-out

Communicate critical information during emergencies.

Purpose of check-back

Verification strategy.

First step of check-back

Sender gives message.

Second step of check-back

Receiver repeats message.

Third step of check-back

Sender confirms accuracy.

CUS stands for

Concerned; Uncomfortable; Safety issue.

C in CUS

Concerned.

U in CUS

Uncomfortable.

S in CUS

Safety issue.

CUS phrase

“Stop the line.”

DESC stands for

Describe; Express; Suggest; Consequences.

D in DESC

Describe situation.

E in DESC

Express feelings and concerns.

S in DESC

Suggest alternatives and seek agreement.

C in DESC

Consequences.

First challenge in the two-challenge rule

State concern.

Second challenge in the two-challenge rule

Restate concern.

Feedback should be what?

Timely; respectful; specific; directed; considerate.

Handoff definition

Transfer of information between providers.

SBAR purpose

Standardized communication.

Task assistance purpose

Protect team members from overload and decrease errors.

Brief occurs when?

Before care begins.

Purpose of a brief

Assign roles; set expectations; anticipate outcomes.

Huddle occurs when?

During care.

Purpose of a huddle

Problem solving.

Debrief occurs when?

After an event.

Purpose of a debrief

Improve performance.

Purpose of situation monitoring

Create situational awareness and a shared mental model.

Situation monitoring should occur when?

During procedures and before mutual support.

STEP stands for

Status; Team; Environment; Progress.

S in STEP

Status.

T in STEP

Team.

E in STEP

Environment.

P in STEP

Progress.

Status includes

Patient history; vital signs; medications; assessment; plan of care.

Team includes

Fatigue; workload; stress; skills.

Environment includes

Resources; equipment; acuity; triage ability.

Progress includes

Goals; priorities; evaluation.

Cross monitoring definition

Watching each other’s backs.

Cross monitoring provides what?

A safety net.