Patient Safety and Quality Notes
Safety & Quality
Safety Definition: Freedom from accidental injuries; ensuring patient safety involves minimizing errors and maximizing interception of errors (Institute of Medicine - To Err Is Human, 2000).
Safe Care Definition: Avoiding injuries to patients from intended care (Institute of Medicine - Crossing the Quality Chasm, 2001).
Agency for Healthcare Research and Quality: 6 domains of healthcare quality exist.
Statistics
Medical errors cause 250,000 deaths per year.
7,000 - 9,000 annual deaths are related to medications.
Medical errors are the 3rd leading cause of death.
Heart Disease is the 1st leading cause of death, and Cancer is the 2nd.
Error Placement
Sharp End (Active): Providing patient care and responding to patient needs.
Active errors are unpredictable, with immediate effects.
Blunt End (Latent): Flaw in the system, not immediately leading to error, but a triggering event can cause the error.
Latent errors are dormant
Intervention prevents harm.
Error Levels
Sentinel Event: Unexpected death or serious physical or psychological injury, or risk thereof.
Examples: Unanticipated death, removing the wrong limb, infant dropped, suicide.
Adverse Event: Unintended harm by act of commission or omission.
Examples: Fall, medication error, pressure ulcer.
Near Miss: Unplanned event that did not result in patient injury, illness, or damage due to chance.
Example: Mistake, by chance, harm didn't occur.
Error Types
Diagnostic: Diagnosis delay, not using the right tests, or acting on monitoring.
Treatment: Wrong performance of skill/test, wrong dose/method of medication, delay of treatment, ignoring abnormal results.
Prevention: Not giving prophylactic treatment, inadequate monitoring, follow-up.
Communication: Lacking or unclear communication leads to many types of errors.
Error: Commission vs. Omission
Omission: Didn't do something, but should have.
Commission: Gave incorrect care.
Error: Prevention vs. Mitigation
Prevention: Lethal error discovered and stopped before it happened.
Mitigation: Early mistake discovery and countered.
Just Culture
Seeks to balance learning from mistakes with disciplinary measures.
Aims to find a balance between the need to learn and corrective action.
Individuals are still accountable for actions.
Does not apply to criminal behavior or delayed reporting.
Promotes reporting of adverse events to analyze lessons and prevent future injuries.
Injury-reporting rates drop without just culture.
QSEN (Quality & Safety Education in Nursing)
Knowledge: Avoiding tech workarounds and unsafe practices.
Human Factors: Interruptions, waiting for systems, disjointed services.
Skills: Communicating hazards/concerns with others, using tools (incident reports), and standard practices to reduce risk of harm to self/others.
Attitudes: Collaboration across teams for safe coordination and vigilance by all team members (patients, families, all staff).
Nurse’s Role in Safety
Preventing IV & Feeding Tube Mix-Ups
Swiss Cheese Model
Errors occur despite multiple safeguard layers.
Creating a Culture of Safety
Minimizes risk of harm to patients through system effectiveness and individual performance.
Incident Reports
NEVER document the presence of an incident report in the patient chart.
Used by the facility to improve quality.
Document what happened to the patient and who you notified.
Example Nurse Note: Chart procedure, how patient tolerated it, notification of the provider to obtain new order to restart IV.
Incident Report Content: Time/Date/Occurrence/Type of Error/Events/Patient Status/Who was notified
National Safety Efforts
QSEN: Quality & Safety Education for Nurses.
National Patient Safety Goals: Initiated by The Joint Commission; asks hospitals to focus attention on series specific actions.
Institute of Medicine: Safety is one of 6 Aims created by IOM to improve Healthcare Quality.
Conclusion
Quality improvement is a continuous process; there is no perfect result.