Class 21: Quality control and risk management

CPSI competencies

Patient safety culture (reporting mistakes)

Teamwork

Communication

Safety, risk, and quality improvement 

Optimize human and system factors 

Recognize, respond to and siclose patient safety incidents 

Aspects of people centred care

Integrity and relevance

Communication and trust

Inclusion and preperation

Humility and learning

Principles of high reliability organizations

Preoccupation with failure (Members are concerned with safety)

Reluctance to simplify (Not taking shortcuts, look deeper for reasons)

Sensitivity to operations (Understand how systems work)

Commitment to resiliency (Learn from mistakes)

Deference to expert opinion (Refer to experts)

High reliability organizations

Has fewer accidents, incidents, and events than whats expected

Tools to manage risk

Standardized assessments/interventions:

Braden scale

Med checks

Guardrails for Iv drugs

Preop checklist

Daily rounds/huddles

SBAR

Triage checklist

Nurses role in quality improvement 

Main: follow policies/procedure

preventing complications (med errors, infxn etc)

Listen to pts

Add

Nurse managers role in quality improvement 

Observe staff (are they following policy?)

Scheduling 

Dealing with concerns 

Promoting a safe unit culture 

Team leaders role in quality improvement

Lookign at big picture of incidence reports

Educational opportunities

Staffing and resources

Taking feedback

Steps in quality improvement process

Assemble the QI team
Identify the aim: What are we trying to accomplish?
Identify the measures: How will we know if a change is an improvement?
Defining the changes: What changes will result in an improvement?
Implement rapid cycle improvements
Sustain the improvements

Never events

Errors in care that are clearly identifiable , preventable, serious in consequence

Ex: Counting all supplies in OR to make sure nothings left in pt 

Sentinel event 

Serious, unexpected occurence involving death or physical or psychologic harm

Ex: Amputating wrong limb

Near miss

Situation resulting in no harm but highlights problem that must be corrected

Importance of incidence reports, if a bunch of people having same near miss can help prevent incidence 

Root-cause analysis

Deeper review of incident and sequence of events that led to it

Ex: unit have lots of falls, look into why