Patient Safety

What is the third leading cause of death in the US?

medical error

Error of Omission

action not taken

Error of Commission

wrong action taken

Swiss Cheese Model

every step in the process has to have a hole in it, and it all has to line up for an error to occur

What is the leading cause of medical error?

poor communication

Why are nurses so important in preventing medical error?

the eyes and ears of the team; identify and community patient needs and changes; often the last point of care before errors occur

Errors can be ______ at any level.

stopped

When should medication reconciliation be done?

at every transition of care

Medication Reconciliation

compares list of current medications against new orders

Why is tall man lettering used?

to distinguish LASA drugs

What are some high alert medications?

anticoagulants, insulin, chemotherapeutics, anesthetics

What are some top sentinel events?

falls, wrong site, delayed treatment

What are some top reasons for falls?

medications, lower body weakness, balance difficulties, vision deficits, pain, poor footwear, hazards in the room, delirium, incontinence

What is the most common cause of falls?

medications

Restraints must have a __________.

provider order

How often must a restraint order be renewed?

every 24 hours

Line Reconciliation

recheck the connection and trace tubes and catheter to their sources

High Risk Factors for VTE

immobility, fractures, lengthy surgeries, obesity, pregnancy

What are some of the first signs of patient distress?

changes in LOC, changes in RR