Pt Safety, Sterility & Organizations

NASEM-National Academy of Sciences, Engineering & Medicine

formerly IOM (Institute of Medicine), established. 1970, INDEPENDENT NGO, non profit that works outside gov & private sector to provide unbiased authoritative advice to make informed health decisions by providing evidence, Health & Medicine Division, to Err is Human Report (1999)

To Err is Human

human error predictable, 98,000 lives lost annually from medical errors in hospitals now 700,000 death or serious disability, recognizes connection between quality care & pt safety, improvement requires system-wide changes (preventing, mitigating, recognizing)

Medical Errors

the improper execution of a plan, failure of planned action to be completed as intended, or use of improper plan to achieve aim

Who plays a role in ensuring Pt safety/quality care?

National Center for Pt Safety (AHRQ), Consumers, Professionals & Accreditation Groups, Mandatory & Voluntary Reporting, CULTURE of SAFETY

AHRQ-Agency of Healthcare Research & Quality

produce evidence to make healthcare safer, more accessible, equitable & affordable, with US Dept of Health & Human Services, created TEAM STEPPS

TEAM STEPPS Elements

communication strategies, situational monitoring, mutual support, leadership strategies…planning/brief (short session before start, assign roles, establish expectations, climate to anticipate outcomes), Huddle/Problem Solving (ad hoc planning, re-establish situational awareness, reinforce plans already in place, adjustments), Process Improvement/Debrief ( informed information exhange session designed to improve team performance after action review)

Situational Awareness/Monitoring Process

create shared mental model so all on same page, DURING procedure/event, proceeds mutual support, Situation Monitoring (individual)>Situation Awareness Outcome (individual)>Shared Mental Model (team outcome)

Quality & Safety in Nursing Education-QSEN

pt centered care, team work (SBAR, rapid response teams), evidence based practice, Quality & Improvement (culture of safety), Safety, Informatics (databases)

Key Components in Culture of Safety

commitment to safety (at all levels of org), leadership, communication, environment, high risk, error prone nature of work, blame free environment (individuals able to report errors or near misses without fear of reprimand or punishment), collaboration, org direct resources to addressing safety concerns

Human Error

predictable, lapse in personal behavior, need to understand how mistakes made & decrease likelihood of error

Human & Systems Factors

study of human behavior, abilities, limitations & other characteristics as they affect design & smooth operation of equipment, systems, jobs & work environment

Sentinel Error

adverse event causing DEATH or SERIOUS INJURY, not anticipated or expected

Adverse Event

harmful or undesirable event associated with medical care, not to level of sentinel, ADE (adverse drug event) undesired occurrence related to drug

Medication Event

any PREVENTABLE occurrence that can lead to incorrect or unintended medication administration (prescribing, dispensing, administering)

Root Cause Analysis

process for identifying casual or contributing factors underlying AE or other critical incidents, identify underlying problems that increase likelihood of error NOT focus on individual failing

strategies to eliminate errors & unsafe practices

open communication, organizational error reporting, rounding to closest ¼ hr, peer checking, checklists, 60 sec situational awareness, pt ID, safety enhancing tech

MOST to LEAST helpful error reducing strategies

forcing functions & constraints, automation & computerization, standardization & protocol, checklists & double check sys, rules & policy, education & information, “be more careful“

Unsafe Practices

work arounds , deviation from expected pattern of work to achieve an end result by bypassing safety features, dangerous abbreviations, relying on memory

medical asepsis

REDUCTION of disease producing organisms

Surgical Sepsis

DEVOID of pathogens, elimination of all microorganisms including spores

RACE

rescue, alarm, contain, extinguish

Sterile/Surgical Asepsis Considerations

sterile packages wrapped, edges of wrappers (1 inch from outer lips NOT sterile, raise working surfaces to waist, height, sterile gloves between nipple line & waist, back=not sterile (DO NOT TURN BACK), below waist NOT STERILE, Do NOT reach over, torn/punctured/wet/open packages NOT sterile, in contact with wet surface=NOT STERILE