Topic 5 Flashcards

310

Communication (in healthcare)

Two-way exchange of timely, accurate, complete information among patients and health-care workers to ensure safe, high-quality care.

Patient Safety

Prevention of errors and adverse effects to patients associated with health care.

Safety (IOM definition)

Prevention of harm to the patient.

Quality and Safety Education for Nurses (QSEN)

U.S. initiative that defines essential nursing competencies, including safety and effective communication.

The Joint Commission (TJC)

U.S. accrediting body that sets patient-safety goals; attributes 60–70 % of reported errors to miscommunication.

Agency for Healthcare Research and Quality (AHRQ)

Federal agency that funds research and develops evidence-based tools to improve patient safety and communication.

World Health Organization (WHO)

Global body that defines patient safety and publishes tools such as the Surgical Safety Checklist.

Standardized Communication

Use of agreed-upon formats and tools to make messages clear, complete, and consistent.

SBAR

Structured verbal tool—Situation, Background, Assessment, Recommendation—for concise, critical communication.

Handoff

Transfer of responsibility for patient care from one caregiver or team to another; high-risk time for errors.

Near Miss

An event that could have led to patient harm but did not, either by chance or timely intervention.

Just Culture

Work climate that balances system accountability and individual responsibility, encouraging non-punitive error reporting.

Culture of Safety

Organizational commitment where safety is a shared value, open communication is encouraged, and staff feel free to speak up.

Crew Resource Management (CRM)

Team-communication model from aviation adapted to health care to reduce errors through assertive inquiry and teamwork.

Briefing

Short pre-procedure meeting where the team reviews the plan, roles, and potential problems.

Debriefing

Post-event discussion to identify what went well and what needs improvement for future safety.

Two-Challenge Rule

Safety tactic in which a staff member voices a concern twice; if not acknowledged, the action is stopped for reassessment.

Checklist

Structured list of evidence-based steps designed to ensure critical tasks are not missed.

WHO Surgical Safety Checklist

Global 19-item checklist that nearly doubled adherence to surgical standards and reduced complications.

SHARE Handoff Tool

TJC mnemonic—Standardize, Hardwire, Allow questions, Reinforce, Educate—for safe handoffs.

I PASS the BATON

TeamSTEPPS mnemonic for comprehensive handoff communication from Introduction to Next steps.

TeamSTEPPS

AHRQ program—Team Strategies & Tools to Enhance Performance & Patient Safety—teaching evidence-based team communication.

Comprehensive Unit-based Safety Program (CUSP)

AHRQ toolkit integrating teamwork, communication, and evidence review to build safety culture.

Patient Identifier Number

Unique ID that links patient data across settings; lack of one is a communication barrier in the U.S.

Fatigue

Physical/mental exhaustion that doubles error risk, especially in the last hours of ≥12-hour shifts.

Workaround

Non-approved shortcut that bypasses safety protocols, increasing risk for error.

Transforming Care at the Bedside (TCAB)

IHI/RWJF initiative empowering bedside nurses to redesign systems for safer, patient-centered care.

Electronic Health Record (EHR)

Digital, longitudinal patient record that supports decision support, data sharing, and safer care when properly documented.

Medication Reconciliation

Process of comparing a patient’s medication orders to all meds the patient has been taking to avoid errors.

Barcode Medication Administration (BCMA)

Technology that matches scanned patient ID and drug barcode to reduce medication errors.

Radio-Frequency Identification (RFID)

Chip-based tracking used for patient ID, staff location, or medication tracking to enhance safety.

Whiteboard (Patient)

In-room board listing key info (preferred name, allergies, daily goals) that supports shared communication.

Bedside Rounds

Interdisciplinary discussions held at the patient’s bedside to include the patient in the care plan.

Interdisciplinary Rounds

Regular team meetings of physicians, nurses, pharmacists, therapists, etc., to coordinate patient care.

Time-out (Surgical)

Mandatory pre-procedure pause to confirm correct patient, site, and procedure, preventing wrong-site surgeries.

Teach-Back

Technique where patients repeat information in their own words to confirm understanding.

Health Literacy

Patient’s ability to obtain, process, and understand basic health information for decisions.

Evidence-Based Practice (EBP)

Integration of best research evidence with clinical expertise and patient values.

Simulation

Use of realistic scenarios to practice clinical and communication skills in a safe environment.

Safety Climate

Shared perceptions about the importance of safety within a unit or organization.

Adverse Medication Event

Patient harm resulting from exposure to a drug; occurs in at least 5% of hospitalized patients.

Sentinel Event

Unexpected occurrence involving death or serious injury; signals need for immediate investigation.

Informatics Competency

Ability to use technology and data to support safe, efficient nursing care.

Moral Distress

Feeling of knowing the right action but being constrained from acting, common in ethically challenging situations.

Informed Consent

Patient’s voluntary agreement to a procedure after receiving full disclosure of risks, benefits, and alternatives.

Confidentiality

Ethical and legal duty to keep patient information private and share only with authorized individuals.

HIPAA

U.S. law that sets standards for protecting patient health information privacy and security.

ANA Code of Ethics

Nine provisions that guide nurses’ ethical obligations, including respect, advocacy, and confidentiality.

Scope of Practice

Legal boundaries defining activities permitted for a profession under state or national regulation.

Malpractice

Professional negligence that results in harm; requires duty, breach, causation, and damages.

Tort

Civil wrong causing injury or harm for which the court can impose liability.

Mandatory Reporting

Legal requirement to report certain issues—e.g., abuse, communicable diseases, threats of harm—despite confidentiality.

Surrogate Decision Maker

Legally authorized person who consents to care when the patient lacks decision-making capacity.

Health Information Technology (HIT)

Electronic systems (EHRs, decision support, e-prescribing) designed to improve quality and safety of care.