1. PATIENT SAFETY AND QUALITY IMPROVEMENT EDUCATIONAL STRATEGY

2. Theory bursts were adapted from Phase III of the Robert Wood Johnson Foundation - Quality and Safety Education for Nurses Education initiative. The Quality and Safety Education for Nurses Education Consortium (QSENEC) is a national initiative of the American Association of Colleges of Nursing (AACN) to enhance quality and safety content throughout nursing courses in entry-level nursing programs. This project is generously funded by The Robert Wood Johnson Foundation. 2

3. OBJECTIVES OBJECTIVES 1. Apply quality improvement tools for process and system improvement. 2. Articulate awareness of strategies to mitigate harm through the systems approach. 3

4. THEORY BURST 1 THEORY BURST 1 PATIENT SAFETY 4

5. Minimize risk of harm to patients and providers through both system effectiveness and individual performance. 5 Source: Quality and Safety Education for Nurses (2013). Competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas/http://qsen.org/competencies/pre-licensure-ksas/

6. http://qsen.org/videos/the-josie-king-story PATIENT SAFETY 6

7. TABLE DISCUSSION 7 In what ways could or should the nurse have recognized risks to Josie‘s safety? PATIENT SAFETY

8. 8 There are numerous threats to patient safety* and errors can occur at all interfaces of care delivery. * Defined on next two slides PATIENT SAFETY SIGNIFICANCE OF PROBLEM

9. The Institute of Medicine defined patient safety as: freedom from accidental injury. Source: AHRQ (n.d.). PSNet Patient Safety Network. Patient safety. Retrieved from http://psnet.ahrq.gov/glossary.aspx#Phttp://psnet.ahrq.gov/glossary.aspx#P PATIENT SAFETY IOM 9

10. Errors are defined as, the “ failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. Source: AHRQ (n.d.). Chapter 1. Understanding medical errors. Retrieved from http://archive.ahrq.gov/quic/report/mederr4.htmhttp://archive.ahrq.gov/quic/report/mederr4.htm PATIENT SAFETY IOM and “Errors” 10

11. PATIENT SAFETY Where Do Errors Take Place? Places where errors take place include: medication administration wrong site surgery equipment failure change of shift reporting incorrect labeling of laboratory specimens 11

12. THEORY BURST 2 Systems Thinking Approach 12

13. SYSTEMS THINKING APPROACH 13 Sherwood, G., & Barnsteiner, G. (Eds.). (2012). Quality and safety in nursing: A competency approach to improving outcomes.

14. SYSTEMS THINKING APPROACH A system is any group of interacting, interrelated, or interdependent parts that form a complex and unified whole that has a specific purpose. Source: Senge, P. (1990). The fifth discipline: The art and practice of the learning organization. 14

15. SYSTEMS THINKING APPROACH Systems thinking is seeing beyond what appear to be isolated and independent incidents to deeper patterns. Recognize connections between events and are therefore better able to understand and influence them. Ability to recognize patterns and interactions. Systems thinking allows the nurse to value and understand how the care of an individual patients is linked to health care outcomes Source: O’Connor, J. & McDermott, I. (1997). The art of systems thinking: Essential skills for creativity and problem solving. Phillips, J., Stalter, A., Dolansky, M., & Lopez McKee, G. (2016). Fostering future leadership in quality and safety in health care through systems thinking. 15

16. SYSTEMS THINKING APPROACH Navigating Webs of Interdependence Peter Senge Whether you are part of a family, organizational team or business in a supply chain, systems thinking is a valuable approach to understanding the complexity of today's world. Peter Senge, author of The Fifth Discipline, Senior lecturer at MIT and Founder of the Society for Organizational Learning shares his perspectives on leadership and systems thinking. https://www.youtube.com/watch?v=HOPfVVMCwYg&index=6&list=PL7JG6 n1ylxVVnKdxkQQ_ikpHZt-5on0V8 16

17. FISHBONE DIAGRAMS FOCUS ON SYSTEMS THINKING FISHBONE DIAGRAMS Doesn’t look for one answer, or the cause. Analyzes how elements and systems work together to create an incident. Explains why there are so many disagreements when people try to identify “the cause” of an incident. Source: ThinkReliability (n.d.) Improving on the Fishbone. Retrieved from http://www.thinkreliability.com/pdf/root-cause-analysis-article-improving- fishbone.pdf http://www.thinkreliability.com/pdf/root-cause-analysis-article-improving- fishbone.pdf 17

18. FISHBONE DIAGRAM What is a fishbone diagram?........ https://www.youtube.com/watch?v=BW4qvULMJjs 18

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20. SYSTEMS THINKING APPROACH Fishbone Diagram Complete in Assigned Groups 20

21. SYSTEMS THINKING APPROACH Steps To Complete A Fishbone Diagram 1. Break into assigned groups. 2. Review the case study to examine the impact of a medication error from a systems perspective. 3. Complete one branch of a fishbone diagram—staff, work environment, admission process, or computer system. 21

22. SYSTEMS THINKING APPROACH 4. Identify underlying causes for the medication error that resulted in deterioration of the patient’s medical condition as described in the case study. Ask: Why? Why? Why? 5. Generate 1 - 2 system improvement recommendations and any immediate corrective actions that address causal factors within the assigned individual branch. 6. Exchange a fishbone diagram with another student group that completed a different branch. Provide feedback to group members about clarity of completed branch. 22

23. SYSTEMS THINKING APPROACH Fishbone Diagram Report Out to All Groups and Revisions 23

24. SYSTEMS THINKING APPROACH 7. Present assigned branch to entire group. 8. In original group, revise fishbone diagram using feedback from faculty and peers. 24

25. IMPROVING PATIENT SAFETY What have we learned today? 1. Name several nursing actions that may prevent a medication error. 2. Explain the primary purpose in completing a fishbone diagram. 3. Identify strategies to mitigate harm through the systems approach. 25

26. SUMMARY: IMPROVING PATIENT SAFETY “Safe, effective delivery of patient care requires understanding of the complexity of healthcare systems, limits of human factors, safety design principles…” 26 Source: Sherwood, G. & Barnsteiner, J. (2012)

27. REFERENCES AHRQ (n.d.). Chapter 1. Understanding medical errors. Retrieved from http://archive.ahrq.gov /quic/report/mederr4.htm AHRQ (n.d.). PSNet Patient Safety Network. Patient safety. Retrieved from http://psnet.ahrq.gov/glossary.aspx#P. O’Connor, J. & McDermott, I. (1997).The art of systems thinking: Essential skills for creativity and problem solving. St. Louis, MO: Elsevier. Phillips, J., Stalter, A., Dolansky, M., & Lopez McKee, G. (2016). Fostering future leadership in quality and safety in health care through systems thinking. Journal of Professional Nursing, 32(1), 15-24. Senge, P. (1990). The fifth discipline: The art and practice of the learning organization. New York: Currency Doubleday. Sherwood, G., & Barnsteiner, G. (Eds.). (2012). Quality and safety in nursing: A competency approach to improving outcomes. Ames, IA: Wiley-Blackwell. ThinkReliability (n.d.). Improving on the fishbone. Effective cause-and-effect analysis: Cause mapping. ® Retrieved from http://www.thinkreliability.com/pdf/root-cause-analysis-article-improving-fishbone.pdf 27