Safety & Injury Prevention in Healthcare

Safety in Health Care

• Definition of Safety (IOM): Freedom from accidental injury by avoiding injuries to patients from the care that is intended to help them.

  • Focus on evidence-based practice.

  • Collaboration with patients and families to observe and report gaps or omissions in care.

• QSEN (Quality and Safety Education for Nurses): Minimizing the risk of harm to patients and providers through system effectiveness and individual performance (competency).

Levels and Types of Errors

• Levels of Errors:

  • Adverse Event: Commission or omission that results in unintended harm, not related to the underlying disease or condition.

  • Near Miss: Commission where improper care was provided, but it did not result in harm.

  • Sentinel Event: Unexpected occurrence involving death or serious injury.

• Types of Errors:

  • Diagnostic: Delay in diagnosis, failure to employ tests, use of outmoded tests, failure to act on results.

  • Treatment: Wrong treatment, avoidable delay.

  • Preventative: Failure to provide prophylactic treatment or inadequate monitoring/follow-up.

  • Communication Failure: Lack of communication or lack of clarity in communication.

Placement of Errors

• Active Errors:

  • Made by providers (physicians, nurses, technicians) who are on the front line of patient care.

  • At the “sharp end” of the stick, which refers to the point of care.

  • Examples: giving wrong medication, wrong patient, wrong treatment.

• Latent Errors:

  • Potential contributing factors that are hidden and 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 that does not lead to immediate error but creates a situation that leads to a triggering event for an error (Swiss Cheese Model).

Swiss Cheese Model

• Illustrates how latent and active failures can align to cause errors.

• Active Failures: Unsafe acts by those in direct contact with the patient or system (slips, lapses, fumbles, mistakes, procedural violations).

  • 'Sharp end' of the process involving RNs, PharmDs, MDs, DOs, and RTs.

• Latent Failures: Administrative level decisions leading to error-provoking conditions.

  • 'Blunt end' of the process.

  • Dormant; requires proactive vs. reactive approaches.

Consequences of Human Error

• Human Error: Inadvertent action, slip, or lapse in practice.

• At Risk Behavior: A behavioral choice that increases risk because the individual does not recognize the risk or believes the action's benefit outweighs the risk.

• Reckless Behavior: Consciously disregarding a substantial risk.

Culture of Safety

• Focus on patient outcomes instead of blame.

• Root cause analysis: What went wrong, rather than blaming the individual clinician.

• Communication guided by mutual trust, shared perceptions of safety, and confidence that error prevention strategies will work.

• Acknowledges complexity of healthcare systems and human factors that affect safety.

• Accountability is essential: it is a professional attribute.

• Disclosure: How to inform patients/families about an error.

Environmental Contributions

• Disjointed supply sources

• Missing or nonfunctioning supplies and equipment

• Repetitive travel

• Interruptions

• Waiting for systems/processes

• Difficulty in accessing resources to continue care

• Breakdown in communication

• Communication media issues

Just Culture & Transparency in Health Care

• A system’s explicit value of reporting errors without punishment.

• People can report mistakes without reprisal or personal risk.

• Individuals are still accountable for intentional harm or incompetence.

• Transparency: Provision of information to patients and families to allow informed decisions about where and from whom to receive care.

• Open communication and information sharing with patients and families, including adverse and sentinel events.

Nursing Care and Safety Exemplars

• Fall prevention in different settings.

• Medication administration in hospital settings.

• Care coordination among the team includes the patient.

• Team systems: promotion of high-functioning teams.

• Error reporting: essential to harm prevention; reluctance to report errors hinders a just culture.

Joint Commission & National Patient Safety Goals

• Identify clients correctly

• Improve staff communication

• Use medications safely

• Use alarms safely

• Prevent hospital-acquired infections

• Identify client safety risks, including suicide risk.

• Universal protocol for preventing adverse events in surgery.

ISBAR

• Situation, Background, Assessment, Recommendation - A structured communication method.

Need To Know

• SSI’s (Surgical Site Infections)

• CAUTI’s (Catheter-Associated Urinary Tract Infections)

• CLABSI’s (Central Line-Associated Bloodstream Infections)

• Insulin Usage

• DVT (Deep Vein Thrombosis)

• Pressure Injury