Safety

IOM definition: freedom from accidental injury; avoiding injuries to patients from the care that is intended to help them
Focus on using evidence
Collaboration with patients and families to observe and report gaps or omissions in care to help avoid errors
Quality and Safety Education for Nurses (QSEN): minimizing risk of harm to patients and providers through both system effectiveness and individual performance (competency)

Levels:
- Adverse event: commission or omission, unintended harm not related to underlying disease or condition
- Near miss: commission — improper care provision, did not provide care
- Sentinel event: unexpected occurrence involving death or serious injury
Types:
- Diagnostic: delay in diagnosis, failure to employ tests, use of outmoded tests, failure to act on
- Treatment errors: wrong treatment, avoidable delay
- Preventative errors: failure to provide prophylactic treatment or inadequate monitoring or follow-up
- Communication failure: lack of communication or lack of clarity in communication

Human Error = inadvertent action slip or lapse in practice
At Risk: behavior choice that increases risk by not knowing the risk or thinking that the action’s benefit outweighs the risk
Reckless: consciously disregard a substantial risk

Active:
- Made by providers such as physicians, nurses, and technicians who are front-line in provision of patient care
- At the “sharp end” of the stick — point of care
- Examples: giving wrong medication, wrong patient, wrong treatment
Latent:
- Potential contributing factors that are hidden and lie inactive in the health care delivery system
- Originate at more remote aspects of the health care system, far removed from the active end
- Flaw in the system — does not lead to an immediate error but creates a situation that leads to a triggering event for an error (Swiss Cheese Model)

PATIENT / Sharp End / ACTIVE Errors — Unpredictable; Effects immediate
Latent Errors — Dormant; Intervention prevents harm
Blunt End
Figure reference: Types of errors in health systems
Summary:
- Active/Sharp End: errors by those in direct contact with patient
- Latent/Blunt End: systemic factors that can allow errors to occur

The Swiss Cheese Model describes how errors occur through a combination of active and latent failures.
Active failures are unsafe acts by front-line providers (the 'sharp end'), such as slips and mistakes.
Latent failures are hidden, long-lasting systemic weaknesses (the 'blunt end') that create conditions for errors. What in my healthcare system lead me to that active failure (examples: nurse patient ratio, no barcode scanning)

Focus on patient outcomes instead of blame
What went wrong? Not blaming the individual clinician: root cause analysis
Communication guided by mutual trust, shared perceptions of safety, and confidence that error prevention strategies will work
Acknowledges complexity of systems in health care and human factors that affect safety
Accountability matters though — it is a professional attribute
Disclosure: how to tell a patient/family about an error

A system’s explicit value of reporting errors without punishment
People can report mistakes without reprisal or personal risk
Individual people are still accountable for intentional harm to a patient or incompetence
Transparency means the system allows for provision of information to patients and families that allows them to make informed decisions about where and from whom to receive their care
Transparency also means open communication and information sharing with patients and families, including about adverse and sentinel events

Fall prevention — in different settings where nurses provide care and teaching for risk prevention
Medication administration — hospital setting
Care coordination — among the team includes the patient
Team systems — promotion of high-functioning teams
Error reporting — essential to harm prevention, reluctance to error reporting and a just culture

Joint Commission & National Patient Safety Goals (reference link provided in transcript)

SSI’s (Surgical Site Infections)
CAUTI’s (Catheter-Associated Urinary Tract Infections)
CLABI’s (likely CLABSI — Central Line-Associated Bloodstream Infections; transcript spellings vary)
Insulin Usage
DVT (Deep Vein Thrombosis)
Pressure Injury