2) Clinical Safety: The Core of Leading, Managing, & Following

A nurse manager is implementing strategies to support the steps in the AHRQ document "Five Steps to Safer Health Care." What does the manager include in the implementation? a. Patients are actively encouraged to make decisions related to care. b. Rules and decisions are made through centralized processes. c. You monitor the performance of each staff member closely. d. Preference is given to increasing staff numbers rather than staff credentials.

*a. Patients are actively encouraged to make decisions related to care* The Agency for Healthcare Research and Quality (AHRQ) outlines "Five Steps to Safer Health Care," which suggests that safe, patient-centered care is facilitated by assisting patients to become active partners in their own care.

Sarah is a second-year nursing student. The clinical instructor overhears Sarah telling a patient that she "always" checks patients' bracelets before giving medication and she is not sure how the nurses on the unit "get away with" not making more errors than they do. The clinical instructor pulls Sarah aside and explores with her how her communication might affect the patient and what it reflects about her beliefs related to the team. What competency does this action outline? a. QSEN b. IHI c. DNV/NIAHO d. AHRQ

*a. QSEN* The Quality and Safety Education for Nurses (QSEN) project provides resources related to competencies that prelicensure and graduate students need to develop to serve as safe practitioners. These competencies include leading and managing, teamwork and collaboration.

What facilitate the development of decision-making skills related to safe patient care for a nurse manager? a. Regular reflection on decisions b. A culture of perfectionism c. Recognition of who should be held responsible for individual errors d. A culture of trust between the staff and you

*a. Regular reflection on decisions* Reflection on how well decisions were enacted enables knowledge of the complexity of situations and ramifications of the decisions made. Reflection enables elimination of strategies and methods that are inappropriate in meeting needs and aids in narrowing choices of best actions to take.

Pleasant Valley Hospital has amended its safety practices and policies. What has the hospital elected to emphasize accordance with changes by The Joint Commission (TJC)? a. Safety goals specific to Pleasant Valley b. Decision-making processes c. Sufficient staffing for safe care d. Increased numbers of baccalaureate-prepared RNs

*a. Safety goals specific to Pleasant Valley* When TJC, a not-for-profit organization that accredits healthcare organizations, changed its focus from processes to outcomes, it emphasized patient safety and issues setting-specific annual patient safety goals.

A client requires an appendectomy. The surgeon explains the procedure and asks the client to sign the consent. The patient speaks very little English and looks worried. What is the appropriate action by the nurse? a. Suggest that an interpreter explain the procedure to the client and answer any questions. b. Ask the client if he has any questions. c. Draw a picture to show the incision. d. Not intervene.

*a. Suggest that an interpreter explain the procedure to the client and answer any questions* The 5 Steps to Safer Patient Care identifies that encouraging patients to ask questions when there are doubts and concerns and ensuring understanding before surgery is performed are ways in which nurses can support patients in having greater influence in their own care. In this situation, asking an interpreter to help enables access to information for the patient and active assessment of his understanding.

The nurse is educating older adult patients on staying safe in the healthcare system. What information does the nurse include in the teaching? a. The need to understand and record all medications being taken. b. Bringing their own linens and other personal items to the hospital. c. Washing hands frequently while in a healthcare environment and using a hand sanitizer. d. Following closely the directions and orders of healthcare providers.

*a. The need to understand and record all medications being taken* The Five Steps to Safer Health Care for patients include keeping a list of medications that patients are taking.

During review of back injuries, it is determined that a large number of injuries are occurring in spite of mechanical lifts being used. Furthermore, it is determined that some lifts are outdated. In addressing this concern, the unit manager: a. meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure. b. after consultation with the staff about the review, orders new lifts to replace older ones that are malfunctioning. c. blames the system for inadequate funding for resources. d. reviews the system of reporting incidents to ensure that appropriate reporting is occurring.

*a. meets individually with nurses who are observed to be using the lifts incorrectly to review the correct procedure* The involvement of staff nurses in safety on the unit is imperative in improvement of quality and the provision of patient care. This is a relationship engagement by the manager to engage the nurses and building these relationships improves quality.

What did the IOM Health Professions Education report highlight as a concern for patient safety? a. A normal risk in professional practice b. A result of disciplinary silos c. A reflection of frontline staff d. Related to systems errors

*b. A result of disciplinary silos* The IOM Health Professions Education report (2004) highlighted the education of health disciplines in silos as a major concern in patient safety and endorsed five recommendations. One to be increased and improved communication between the health disciplines.

The NQF provides a model for advancement of healthcare quality that could be used in healthcare organizations. What does the use of this model by the Centers for Medicare and Medicaid Services specificity link with adverse patient events for healthcare facilities? a. Staffing b. Funding c. Composition of executive councils d. Composition of consumer-based councils

*b. Funding* The Centers for Medicare and Medicaid Services (CMS) have adopted a policy based on the NQF's "Never Events." The CMS will no longer pay for patient conditions or events that result from poor practice while patients are under the care of a health professional.

The Rehabilitation Unit at Pleasant Valley Hospital has a high number of falls. What interventions might assist to reduce the number of falls on the unit? a. Determining who is responsible for the falls b. Strengthening unit policies to avoid inappropriate admissions c. Encouraging involvement of nurses in education related to falls and safety d. Ensuring that patients are appropriately restrained if they are at risk for falls

*c. Encouraging involvement of nurses in education related to falls and safety* The IOM (2010) emphasizes the need for nurses to engage in lifelong learning and to use evidence and best practices to inform practice and ensure safety.

How would the nurse executive begin to increase safety in patient care areas of the Valley Hospital? a. Asking the community what the safety issues are b. Consulting with a management expert about staffing schedules c. Ensuring that the senior nursing officer attends the board meetings d. Instituting improved practices to reduce needlestick injuries

*c. Ensuring that the senior nursing officer attends the board meetings* The IOM report (2004) highlighted the importance of the attendance of the senior nurse executive at board meetings to be a key spokesperson on safety and quality issues.

A new graduate nurse is employed in a small community hospital. The nurse notices practices which seem to be very physician driven and that patients have little input into their care. Families are seen as a nuisance rather than as partners in potential care provision. What is the best approach for the new nurse to use for improving care in this setting? A) Do nothing. They are too new to the organization to make change. B) Share with the physician the recommendations from various IOM reports. C) Share with their team members what they know about the aims of providing health care. D) Report the team members to the chief nursing officer who is unlikely to know the lack of details on this unit.

*B) Share with their team members what they know about the aims of providing health care* As accountable professionals, doing nothing is not an option. The chief nursing officer (CNO) is likely to know the standard of care on every unit in a small community hospital and bypassing the unit manager violates a "chain of command" approach. Similarly, going to the physician fails to engage the nursing chain of command. Sharing with team members what the aims of providing health care are provides the opportunity to discuss patient-centered care.

Mr. Grandion was admitted to a rehabilitation center after discharge from a hospital. He has not walked in the 5 days while he was hospitalized and is provided a wheelchair. Dining with other residents is expected, & staffing is limited on a holiday weekend. What is the best strategy to ensure Mr. Grandion has sufficient nutrition & exercise? A) Tell Mr. Grandion to stay in bed and someone will bring a tray to his room because the staff can't get him to the dining room in time for dinner. B) Assist Mr. Grandion into his wheelchair and remind him that in 2 hours he must be in the dining room if he wished to eat. C) Request help from another unit before dinner and indicate the nature of help needed. D) Order a lift device to transfer Mr. Grandion from his bed to the wheelchair.

*C) Request help from another unit before dinner and indicate the nature of help needed* Leaving Mr. Grandion in bed fails to provide any exercise. Assisting him to the wheelchair 2 hours in advance of when he needs to eat may pose physical discomfort and the potential for skin breakdown. Ordering a lift device might be useful, but it might not be timely. Requesting help to prevent personal injury and aiding Mr. Grandion into a wheelchair in a timely manner provides some activity and helps him gain appropriate nutrition.

What would managers and staff review annually in order to ensure compliance with The Joint Commission (TJC) to improve patient safety? a. Appropriateness of charting terms and abbreviations b. Nursing hours per patient c. Acuity of patient admissions d. Wait times for care

*a. Appropriateness of charting terms and abbreviations* The Joint Commission issues setting-specific patient goals annually, as well as a list of "do-not-use" terms, abbreviations, and symbols and sentinel events.

What patients would be considered "at risk" consumers during a healthcare visit? (Select all that apply.) a. Clyde requires an anticoagulant. He tells the nurse about his medications. He does not include an herbal supplement. b. George is very shy and withdrawn. He asks the nurse to leave him alone. c. Sarah is a new parent who finds that nurses on the children's unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand. d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn't know what the doctor meant by colostomy.

*a. Clyde requires an anticoagulant. He tells the nurse about his medications. He does not include an herbal supplement* *c. Sarah is a new parent who finds that nurses on the children's unit are very helpful. She is eager to accept all suggestions, including those that she does not yet understand* *d. Claude is booked for bowel surgery. His doctor explains about the colostomy. Later, Claude tells his wife that he really doesn't know what the doctor meant by colostomy* Safer health care involves the patient as an active consumer who keeps and brings a list of all medications, including natural remedies and questions if there are doubts, concerns, or lack of understanding.

What does the SBAR approach to patient safety encourage? a. Consistency in assessment and practices b. Continuing education c. Multidisciplinary approaches d. Patient feedback

*a. Consistency in assessment and practices* The use of SBAR (Situation, Background, Assessment, and Recommendation) checklists are designed to decrease omission of important information and practices.

You notice that Sally, a student on your unit, is giving information to an anxious young teen who seems very uncertain about preparation for an upper GI series. After Sally leaves the room, you ask her how she thought her conversation with the patient. What is the appropriate response for you to give Sally? a. Encourage her to ask the patient if he has questions or concerns about the procedure. b. Advise her to consider providing the patient with more information. c. Suggest that she leave some brochures on the procedure with the patient. d. Suggest that she also provide teaching to the adolescent's parents.

*a. Encourage her to ask the patient if he has questions or concerns about the procedure* The 5 Steps to Safer Health Care for Patients includes the step of asking questions if there are doubts or concerns. The nurse can encourage patients to take a larger role in care by taking these steps and by providing patients with coaching in the steps.

To achieve Nurse-Sensitive Care Standards developed by the NQF, you advocate for which of the following in your health facility? a. Evidence-based practice to reduce the prevalence of pressure sores b. Implementation of informatics at the bedside c. Staff-manager conferences to review reporting of adverse medical events d. Patient councils to review food, recreation, and nurse-patient relations

*a. Evidence-based practice to reduce the prevalence of pressure sores* The National Quality Forum (NQF) outlines nursing-centered intervention measures related to prevalence of pressure sores, ventilator-associated pneumonias, volunteer turnover, nursing care hours per day, and skill mix of staff.

As a manager in a new nursing home, where might you consult for guidance and evidence to support the development of safe patient practices? a. Hospitals b. Business c. Industry d. Outpatient clinics

*a. Hospitals* Practices that were once mostly studied in hospital settings are now scrutinized for implementation in other settings, such as outpatient clinics, rural settings, and nursing homes.

Mary, an 85-year-old patient with cognitive impairment and gross instability, wanders continuously. Lately, she has fallen twice, and the family demands that she be restrained. As the unit manager, you have initiated a least restraint practice. What is an appropriate action in this situation? a. Setting up a nursing team meeting to review practices b. Calling the family to inform them of the practice c. Initiating a multidisciplinary and family meeting to focus on Mary's needs d. Restraining Mary to satisfy the family's wishes

*c. Initiating a multidisciplinary and family meeting to focus on Mary's needs* Crossing the Quality Chasm emphasizes the importance of rendering care with the client (client-centered) rather than to the client. In this situation, the patient includes family in transparent discussions about quality needs and takes a team approach that involves healthcare professionals, the family, Mary's needs, and evidence associated with safe practice.

After consulting with practice environments about quality and safety concerns in health care, a dean in a health care program implements what to improve quality and safety in health care? a. A nursing program that emphasizes the development of a strong disciplinary identity. b. Programming that stresses discipline-based research. c. Partnerships with health care to develop software for the reporting of adverse events. d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams.

*d. An interdisciplinary program for nurses, pharmacists, and medical practitioners that emphasizes collaborative learning teams* Health Professions Education identified that education related to health disciplines in silos leads to compromised communication and inability to function as an integrated whole for patient-centered care.

How would a nurse manager and the staff prepare for redesignation as a Magnet® Hospital? a. Commit staff resources over a 6-month period to updating procedure manuals. b. Educate staff through meetings and training sessions regarding appropriate answers to questions. c. Prepare a manual that outlines orientation procedures and ensure that all safety issues are addressed. d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions.

*d. Ensure that there are empirical data to support review of patient outcomes, actions taken, and results of actions* Through the Magnet® model, organizations must demonstrate how they provide excellence in five areas. Between designation and redesignation as a Magnet® organization, greater emphasis is placed on empirical quality results.

In an effort to control costs and maximize revenues, the Rehabilitation Unit at Cross Hospital reduced the number of its managers and increased the number of units for which each manager was responsible. Within a year, the number of adverse events on the units had doubled. How do the increase in adverse events relate to decreased managers? a. The overload of staff nurse duties b. Resistance to change by staff c. A change in reporting system for everyone d. Fewer clinical leaders facilitate best practice

*d. Fewer clinical leaders facilitate best practice* Eliminating barriers to the implementation of best practices is the role of managers and leaders. When there are insufficient resources for leadership to encourage a culture in which evidence-based practice is embraced, frontline nurses recognize this as a stumbling block for delivering quality care.

As a nurse manager on the West Surgery Unit, you are interested in increasing patient safety and reducing morbidity and mortality on your unit. What recommendations would be consistent with the IOM The Future of Nursing report? a. Careful screening of nursing staff for substance use and abuse b. Increased RN staffing on the unit c. Salary and benefits that reflect nursing accountabilities d. Increase in the percentage of baccalaureate-prepared nurses to 80%

*d. Increase in the percentage of baccalaureate-prepared nurses to 80%* The Future of Nursing advocates for having 80% of the nursing population at a baccalaureate-prepared level. This recommendation reflects research that suggests that improved mortality and morbidity rates occur with a better educated work force.

As the manager on an acute care medical unit, you note that the incidence of medication errors has increased since the implementation of staffing changes. What is an important stratagem to reduce errors? a. Revisit reporting standards for medication errors in your organization. b. Ensure that medication errors are consistently reported. c. Provide staff with additional education related to safe practice in medication administration. d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration.

*d. Involve RN staff in determining reasons for errors and practice solutions to increase the safety of medication administration* Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) identified many past practices that had a negative impact on nurses, and thus on patients, and recommended the inclusion of nurses in direct care in decision making involving their practice. Future of Nursing: Leading Change, Advancing Health (2010) also emphasizes the role of nurses as leaders in changes that improve health.

What would be the primary emphasis in designing and implementing a quality, safe healthcare environment? a. Evidence-based practice b. Informatics c. Staffing d. The patient

*d. The patient* Focusing on the patient moves care from concern about who controls care to a focus on what care is provided to and with patients, which was an aim identified in the IOM report Crossing the Quality Chasm.

On the West Surgery unit, you want to institute a new system for checking armbands that evidence suggests may increase safety in medication administration. The system involves technology. What strategy may assist with rapid adoption of the technology and system? a. Employ a centralized decision-making approach. b. Use simulators for initial practice to build confidence. c. Bring in a nurse consultant who is familiar with the technology. d. Use early adopters among the staff as leaders and role models in implementation.

*d. Use early adopters among the staff as leaders and role models in implementation* The Institute for Healthcare Improvement (IHI) is dedicated to rapid improvement in patient care through a variety of mechanisms such as rapid cycle change. Rapid cycle change diffuses innovation and changes quickly through early adopters who share information and energy over time and act as role models for others.