Safety & Quality Improvements Part 1

common medical errors

- **Medication errors** - Improper transfusions - Too much oxygen for premature babies - Health-care associated infections - Central-line infections - Falls - Surgical errors - Pharmacy errors - Lab errors - Treatment errors - Birth injuries - Restraint-related injuries or death - Burns - Pressure ulcers - Mistaken patient identities

"Just" Culture

- Accountable, non-punitive environment - Do not blame, shame - Partnership of accountability Individuals should not be held accountable for a systems problem - Recognizes that competent professionals make mistakes (note: does not tolerate reckless behavior!) - Acknowledges that competent professionals will develop unhealthy norms (shortcuts, work-arounds) - Supports a learning organization - Leads to greater improvement in patient safety

The Joint Commission

- An independent, not-for-profit organization - Accredits and certifies nearly 21,000 health care organizations and programs in the US - Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards - Monitors safe patient care and ensure patients if it is a safe place

Patient Safety Definition

- IOM definition: "the prevention of harm to patients" - WHO definition: Prevention of errors and adverse effects to patients that are associated with health care - Safety is what patients, families, staff, and the public expect from their health care system

IOM Report on Medical Errors

- IOM report: "To Err is Human: Building a Safer Health System" (1999) - Noted 98,000 people die in US hospitals each year due to medical errors - Highlighted issue of patient safety and quality public/ private policy makers, health care professionals, and consumers

NPSGs 2019 rules

- Identify patients correctly - Improve staff communication - Use medicines safely - Use alarms safely (Alarm Fatigue) - Prevent infection - Identify patient safety risks - Prevent mistakes in surgery

Medical error stats today

- More-recent studies estimate much higher numbers 210,000 to 440,000 pts/year who seek care at a hospital die as a result of medical errors (Over 4 times the original IOM estimate) - More than 1000 people each day - Approximately 10,000 serious complications cases resulting from medical errors that occur each day - Medical errors cost the nation an estimated $1 Trillion each year - Numbers do not account for deaths that occur in outpatient clinics, nursing homes and other non-hospital settings where health care workers care for fragile patients who need complex care

Nursing and Patient Safety

- Patient safety is an essential and fundamental component of quality nursing care - Nurses play a vital role in ensuring patient safety by: * monitoring patients for clinical deterioration * detecting errors and near misses * understanding care processes and weaknesses inherent in some systems * coordinating high-quality care through collaboration with physicians, pharmacists, families, and all other members of the health care team - Promoting safe patient care is important in all areas of nursing practice (clinical, management, education, research, etc.) - Being the patient's advocate is an integral part of nursing practice. Help ensure the patient is safe

National Patient Safety Goals (NPSGs)

- Program established in 2002 first set of NPSGs put into effect January 1, 2003 - Help accredited organizations address specific areas of concern in regard to patient safety - Purpose: improve patient safety - Goals focused on problems in health care safety and how to solve them *Goals specific to setting: - Hospitals - Ambulatory Health Care - Behavioral Health Care - Critical Access Hospital - Home care

Human Error

- Results of current system design and behavior - Educate/train - Change processes - Modify environment *CONSOLE

Responce to medical error

- Serious adverse events require an immediate investigation and response - Accredited organizations are expected to use a "thorough and credible Root Cause Analysis (RCA) and action plan" What are we going to do? - Organizations should disclose the error and apologize to the patient, report the event, and waive all costs associated with the event *Goals - Protect the patient - Improve systems - Prevent further harm

Medical Error Definition

- The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (IOM) - Errors can include problems in practice, products, procedures, and systems

Sentinel Event

- a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition), that reaches a patient and results in any of the following: *Death *Permanent harm (serious physical or psychological injury) *Severe temporary harm and intervention required to sustain life

Key Features or Safety

- acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations - a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment - encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems - organizational commitment of resources to address safety concerns

Ranking Of Medical Errors

1) Heart Disease 2) Cancer 3) MEDICAL ERRORS

Reckless Behavior

Conscious disregard of risk. Deliberate action - Remedial Action - Disciplinary *CORRECT

ZERO deaths 2020

Have no one die from anything preventable

At-Risk Behavior

Individual's choices: "a work around" Risk believed to be justifies or insignificant - Create incentives for heathy behaviors - Increase awareness of risk * COUNSEL