patient Safety By: Kim Peterson

Objectives Identify nurses role in creating a safer environment for patients. Explain how a culture of open acknowledgement of errors and education is critical to improving safety.

Video Safety

Patient Safety & Quality Care Patient Safety…What is it? Do NO harm Freedom from accidental injury Health care systems is prone to error Basic system flaws Medication error Communication error Timely & accurate diagnoses

Patient Deaths Related to Preventable Medical Errors Patient Deaths Related to Medical Errors Patient Deaths Related to Preventable Medical Errors 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 1999 2013 Year

Patient Safety Who is responsible? Nurse educators Administrators Researchers Physicians Government Accrediting agencies The registered nurse (RN)

Nursing Theory Florence Nightingale Environmental Theory “The very first requirement in a hospital is that it should do the sick no harm.” Florence Nightingale

Theory Ronald Lippitt’s Theory of Change Specific & measurable Basis for strategic planning Seven step theory

Assessment of the Environment Interventions Teamwork Education

Assessment of the Environment (cont.) National Patient Safety Goals Voluntary & Mandatory Reporting Methods Just Culture QSEN

Root Cause

Culture of Patient Safety Communication Teamwork Leadership Structured Techniques: SBAR, Time-Out, Read Back Multidisciplinary/Multigenerational Vision/Mission Role Model Clarity Culture of Patient Safety Compassion & Caring Role Model Best Practices Standardization People Evidence-Based Patient-Centered

Patient Safety Challenges Changing the culture Accountability Shortage of RN’s in leadership roles

Patient Safety Outcomes Culture of Safety Essential Elements Positive Environment

Recommendations QSEN Safety Knowledge Skills Value Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects analysis) Participate appropriately in analyzing errors and designing system improvements Engage in root cause analysis rather than blaming when errors or near misses occur Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team Delineate general categories of errors and hazards in care Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems) Communicate observations or concerns related to hazards and errors to patients, families and the health care team Use organizational error reporting systems for near miss and error reporting Value own role in preventing errors The QSEN competency defines safety as Minimizes risk of harm to patients and providers through both system effectiveness and individual performance

Nurses Role Patients entitled to safe care ANA Standards Standard 8 Education Standard 9 EBP Standard 10 Quality of Practice Standard 12 Leadership continuing and improving education and holding one another accountable for the care provided for patients

NCLEX Answers Decide to monitor IV gauges Verbally tell the inserter that the glove is contaminated Have the pump refilled as soon as possible Is demonstrating rebound tachycardia from being off his pre-surgical beta-blocker medication Pause the heparin infusion while the test is being drawn in the opposite arm Adding an additional step to the administration procedure The nurses’ drug guide on the handheld communication device issued by the hospital Administer the substitute medication Request an order for cetirizine hydrochloride Contact the pharmacy for a new dose that is fully labeled

Questions or Comments

References American Nurses Association. (2010). Nursing : Scope and standards of practice. (2nd ed.). Silver Spring, Md.: American Nurses Association. Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in Nursing, 16(3), 5. Hughes, R., (2008). Patient Safety and Quality: An evidence based handbook for nurses. Rockville M.D.: Agency for Healthcare Research and Quality. IOM Report: Patient Safety-Achieving a New Standard for Care. (2005). Academic Emergency Medicine, 12(10), 1011-1012. James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3), 122-8. Kohn, L., Corrigan, J., Donaldson, M., & Ebrary, Inc. (2000). To err is human building a safer health system. Washington, D.C.: National Academy Press. Kritsonis, A., (2004). Comparison of change theory. International Journal of Scholarly Academic Intellectual Diversity, 8(1), 1-7. Mccannon, J., & Berwick, D. (2011). A new frontier in patient safety. JAMA, 305(21), 2221-2. Nursing Theory. (n.d). Retrieved March 20, 2015, from http://www.nursing-theory.org/theories-and-models/nightingale-environment-theory.php Sammer, C., & James, B. (2011). Patient safety culture: The nursing unit leader's role. Online Journal of Issues in Nursing, 16(3), 3. Quality & Safety Education for Nurses (QSEN). (n.d). Retrieved March 20, 2015, from http://qsen.org/