Final Exam

Traditional Approach to Pt safety

Well trained clinicians do not make errors. A culture of blame that made clinicians hesitant to be transparaent with their mistakes.

To Err is Human (2000)

Institue of medecine report that found nearly 100,000 people die in hospital each year from preventable medical errors.

It found that most errors were not a result of incompetent healthcare professionals but rather bad systems that failed to prevent errors.

What are nosocomial infections

Infections are acquired in a hospital or healthcare facility by a patient admitted for a reason other than that infection. They are also known as healthcare-associated infections (HAIs).

UTI Prevention measures

• Ensure proper hydration

• Good perineal hygiene

• Use an appropriate technique for insertion, maintenance and removal of the catheter

  • sterility

  • closed system

  • unobstructed urine flow

Central line associated blood stream infection

• Hand hygiene and skin asepsis

• Follow institution protocols for insertion, dressing changes, tubing changes, removal etc.

• Aseptic lumen access

• Aviod disconnections

• Routine assessments

Airborne precaustions

Infection control measures are used to prevent the spread of airborne diseases like tuberculosis, chicken pox and measles.

They involve:

• wearing masks (N95 respirators to protect oneself)

• Isolating patients in negative pressure rooms

• Using proper ventilation systems.

Droplet precautions

Infection control measures are used to prevent the spread of pathogens transmitted through respiratory droplets.

Common infections requiring droplet precautions:

• Influenza

• Pertussis

• Rubella

This includes wearing masks and maintaining a safe distance.

Canadian Patient Safety Institute (CPSI) competencies

• Patient Safety culture

• Teamwork

• Communication

• Safety Risk and QI

• Optimize Human and system factors

• Recognize, respond to and disclose patient safety incidents

Quailty Assurance vs. Quaility Improvement

QA:

• perfection myth

• Individual focused

QI

• Systems focused

• fallibilty recognized and see an opportunities to learn

PDSA QI Model

Three questions:

1. What are we trying to accomplish

2. How will we know a change is an improvement

3. What change can we make that will result in an improvement

Plan

Do

Study

Act

STEEEP QI model ofr Improvement

Safety

Timely

Effective

Effecient

Equitable

Patient-centered

Outcome measures

Where are we going?

Process measures

what are we doing

Balancing measures

What else is happening