Mod 9: Patient Safety and Care

Radio Frequency Identification (RFID)

A system using radio frequency rather than bar code for similar purposes. Contains a tag affixed to an object or to a person that functions as a radiofrequency transponder and provide a unique identification code; a reader that receives and decodes the information contained on the tag; and an antenna that transmits the information between the tag and the reader

Workflow terminology

A term used to describe the execution of a series of tasks preformed in a prescribed sequence. A progression of steps that compromise a work process

What can technology do to improve patient safety?

1)improved communication 2)guide clinical decisions making and reduce variation in how workers preform the same function 3)enhanced response times to adverse events 4) Hastening reporting of errors and near misses

Computerized Physician Order Entry (CPOE)

A system that automates how medication and care orders are completed, replacing traditional handwritten orders on paper.

Barcode Medication Administration (BCMA)

A system using bar code technology to support medication dispensing and administration. A bar code is affixed to a medication, the patient ID bracelet, and the Nurse ID badge to support the five rights of medication administration.

CDS systems provide many alerts to nurses, ranging from medication-related warnings to health screening recommendations. When nurses encounter too many alerts, which of the following may occur? A. Alarm fatigue B. Safe medication administration C. Enhanced response time to adverse events D. Improved patient safety

A. Alarm Fatique

CDS systems capture significant amounts of data and information, but some healthcare settings find it difficult to implement a CDS system that remains up-to-date with clinical evidence. A. True B. False

A. True

CDS systems may provide meaningless or harmful information. How does this impact nursing practice? A. Nurses will find it difficult to communicate with team members. B. Nurses must decide when to act upon a recommendation and when to disregard a notification. C. Nurses must spend more time gaining accurate information from patients. X D. Nurses will spend a lot much money finding an effective CDS system.

B. Nurses must decide when to act upon a recommendation and when to disregard a notification.

A clinic has decided to implement an EHR system. Many of the nurses are skeptical of the new technology because they will need training and time to adjust, which may lead to decreased patient care in the meantime. If nurses make errors while using this new technology, what can the clinic do to promote a culture of safety? A. Discipline nurses who make errors while using the new technology. B. Revert back to the old paper-based system of collecting patient information. C. Allow nurses and the healthcare team to collaborate on solutions to patient safety problems. D. All of the above

C. Allow nurses and the healthcare team to collaborate on solutions to patient safety problems.

Ken, a board certified cardiac nurse, works in a cardiac care unit. He is inserting a PVC into a patient when an alarm in the hall goes off. During that time, Ken accidentally inserted the PVC into the patient's artery by mistake. Which of the following factors impacted Ken's error? A. Lack of essential knowledge B. Fatigue C. Distraction D. Short staffing

C. Distraction

A clinic has decided to implement an EHR system. Many of the nurses are skeptical of the new technology because they will need training and time to adjust, which may lead to decreased patient care in the meantime. After implementing the new technology, what should the clinic do to ensure that the system is supporting patient safety? A. Upgrade the technology system when an advanced feature becomes available. B. Implement another new technology to have the most up-to-date resources. C. Monitor the technology system to ensure the nurses are able to use it accurately. D. Increase healthcare costs to make up for the cost of implementing the system.

C. Monitor the technology system to ensure the nurses are able to use it accurately

Janice and Roberta are working in the medical-surgical unit of a small hospital and are caring for twenty patients. One of Roberta's patients is due for an antibiotic, but another patient requires her care, so she asks Janice to refill the antibiotic. Janice goes into the patient's room, verifies that it is the correct patient, and administers the antibiotic. Five minutes later the patient alerts the nurse's station and says that his IV site is burning and itching. Janice checks on the patient and realizes that she administered the incorrect antibiotic. Which of the following factors significantly impacted Janice's error? A. Developing a workaround B. Distraction by mobile devices C. Short staffing D. Lack of essential knowledge

C. Short Staffing

Benefits of using the EHR system can be explained to the nurses to make them more comfortable with the new technology. Which of the following is a benefit of using technology? A. The new technology will eliminate medical errors. B. The new technology will increase reimbursements to the clinic. C. The new technology will improve communication, ensuring that the right people have access to necessary information. D. The new technology will reduce healthcare costs.

C. The new technology will improve communication, ensuring that the right people have access to necessary information.

Five students at a local high school have been diagnosed with staph infections. Sarah, a registered nurse, is working in a clinic located near the school. Due to concerns from the public, the clinic experiences a significant increase in patients coming in for treatment. Sarah skips dinner and works overtime to ensure that all patients receive care. On one occasion, she administers penicillin to a patient, who then has a severe adverse reaction. Sarah realizes that she overlooked the patient's allergy list. Which of the following factors significantly impacted Sarah's error? A. Developing a workaround B. Disregard for policies and procedures C. Distraction by mobile devices D. Fatigue

D. Fatigue

Smart Pump

Designed for safe administration of high-hazard drugs and to reduce adverse drug events during intravenous medication administration.

Clinician Decision Support

Helps a clinician select an appropriate medication based on data.

What if technology is implemented without consideration of workflow?

If technology is implemented without consideration of workflow, it can create greater patient safety concerns than if the technology were not implemented at all.

Workflow design

Involves mapping current workflows and planning for the future to improve an organization's efficiency and health care quality (the future state).

Workflow Analysis

Involves observation and documentation of workflow to better understand what is happening in the current environment and determine how it can be altered.

Decision support systems

computer applications designed to facilitate human decision-making process

Five rights of Clinical Decision Support (CDS)

right information in the right person in the right format in the right channel in the right time in workflow