Safety

Flashcards about Safety in Nursing and Healthcare

Safety

Freedom from accidental injuries; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur.

Safe care

Avoiding injuries to patients from the care that is intended to help them.

Safe care

Making evidence-based clinical decisions to maximize the health outcomes of an individual to minimize the potential for harm.

Patient safety

Prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors.

Adverse event

Unintended harm by an act of commission or omission rather than as a result of disease process.

Near miss

Error of commission or omission that could have harmed a patient, but harm did not occur as a result of chance.

Sentinel event

Unexpected occurrence involving death or serious injury.

Diagnostic errors

Errors related to incorrect or delayed diagnosis.

Treatment errors

Errors that occur during a surgery, procedure, medication order, etc.

Preventive errors

Errors that occur when a patient does not receive monitoring or follow-up treatment.

Communication errors

Failure to communicate effectively.

Latent errors

Errors that are not immediately obvious (e.g., faulty equipment design).

Active errors

Errors that are made by providers who are providing patient care (e.g., administering the wrong medication).

Culture of safety

Focus is on what went wrong rather than who to blame.

Knowledge attribute of safety

Focus of safety is on the execution of skills, as well as on technology and systems level.

Skills attribute of safety

Nurses need to use tools to contribute to safer systems.

Attitudes attribute of safety

Nurses and other health care professionals need to value their roles in safety and collaboration.

Reason’s Swiss Cheese Model

Shows how errors occur when situational factors align, despite multiple layers of safeguards for the prevention of errors.

Human Factors

Study of the interrelationships among people, technology, and the work environment.

Crew Resource Management

Situational awareness, problem identification, decision making by generating alternative acceptable solutions, appropriate workload distribution, time management, and conflict resolution.

High-Reliability Organizations

Manage work that involves hazardous environments.

Characteristics of the HRO mindset

Sensitivity to operations, focused on predicting and preventing rather than reacting to errors, reluctance to simplify, and deference to expertise.

Just Culture

A health care system’s value is in reporting errors without punishment.

"Just culture"

Seeks to find a balance between the need to learn from mistakes and the need for disciplinary action against employees.

Transparency in Health Care

Openly sharing information about errors and adverse events with patients and families.

Fall prevention

Minimizing the risk of falls.

Medication administration

Administering medications safely.

Care coordination

Coordinating patient care effectively.

Team Systems

Effective teamwork and systems implementation.

Error Reporting

Reporting errors to improve safety.

Example of Adverse Event

Giving the wrong medication.

Example of Near Miss

When a doctor prescribes the wrong medication, but a nurse catches it.

Example of Sentinel Event

Cutting off the wrong limb, or not repositioning a patient causing a pressure ulcer.

Error of omission

What staff is expected to avoid doing.

Error of commission

What staff does do but should have never done.

Error of execution

Failure to do something correctly.

Safety

Is linked to care coordination, communication, and collaboration.

Safety

Includes health care quality

Team systems

Can be improved with error reporting.

Safety

Is a interrelationship concept with collaboration

Communication

An example is patient advocacy

Knowledge

Can improve a patient's safety during medication administration.

High-Reliability Organizations

Refers to a individual's or organization's ability to reliably and consistently avoid failures.

Human factors

Requires an interrelationship of people and technology.

High-Reliability Organizations

Is a focus on predicting and preventing factors.

Knowledge

Focuses on the execution of nursing skills.

Skills

Requires nurses to know how to use tools to improve patient safety.

Attitude

Means nurses need to value collaboration and safety.

Organizational culture of safety

Includes the need to avoid blame in medical errors.

Near miss

Error, omission, or commission could have caused harm.

Crew resource management

Involves situational awareness and appropriate workload distribution.