NUR 472

What is the difference between: Assessment Evaluation Coordination Communications Collaboration?

Assessment-collect information and analyze it, an example is self assessment for the nurse manager inventory Evaluation-determine if planning and collaboration are working; are we progressing toward our goal? Coordination-working to see that pieces and activities fit together and flow as they should. More concerned with services, such as procedures like x-rays or physical therapy Communication-verbal and written communication skills are necessary to understand information and maeke sure others understand what you are trying to convey to them Collaboration-recognition of the expertise of others within and outside the profession and referral to those other providers when appropriate. Involves some shared functions and common focus on the same overall mission. Focused on problem solving a specific goal involving other people

Describe and provide an example of 3 elements of health care quality.

Three elements of quality are structure, process and outcomes. The structure is the setting in which healthcare services are provided, such as homecare from a nursing agency such as the VNA. The process is the way in which services are delivered, as from a physician, PA, NP or an RN or an interdiscpinary team and where care is delivered. Outcomes are the result of these services. Outcomes can be negative or positive, and are diverse and patient-centered.

Identify 3 characteristics of effective collaboration skills.

1. Communication- skills are critical. Verbal skills are the focus however in some instances written communication is also important. 2. Awareness of personal feelings- Staff members need to be aware of their own feelings (emotional intelligence) 3. Problem solving- need to able to make decisions and solve problems effectively 4. Negotiation- conflicts will arise. Resolve difficult conflicts 5. Assessment- collect information and analyze

What are technique for developing an idea for change?

1. Critical thinking about the current system Sometimes, simply reflecting on problems within a system can generate some good ideas for change. If you make a flow chart of your current process, it might help you identify parts of the system that aren't working well or that are needlessly complex. Another way to go about critical thinking is to gather and analyze data on the way your system currently works — which you can use to help identify problems and develop changes to address them. 2. Benchmarking Comparing your own process to "best practice" can help you identify where your own system falls short. Based on that analysis, you can develop ideas for improving your performance. This is known as benchmarking. Here's another way to think about this idea: Benchmarking in its simplest form is merely looking around at how others are doing things and trying to learn new approaches and possibilities. A formal benchmarking process provides a method with some structure for making these observations, and then using this information for improvement. 3. Using technology-If you're trying to reduce medication errors in your clinic, you might consider bar-coding medicines, or computerized physician order entry (CPOE). These are just two examples of how technology — such as automation, new equipment, or new information systems — can lead to improvement. But be careful! Technology that isn't reliable, or that simply makes a bad system more accessible via the Internet, is not necessarily the fix you're looking for. 4. Creative thinking Where do new ideas come from? You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; temporarily considering unrealistic goals that can prompt you to break out of your old way of thinking; and exposing yourself to situations that can spark new ideas, such as taking the role of a patient to view health care in a different light. 5. Using change concepts A change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Here are some examples.

What are Tuckman's stages of team development? Do these stages occur in a sequential order or are they a random occurrence?

1. Forming- orientation. Team learns about one another, trust is not likely to be high. Focus on developing trust and team member working relationships. Being assessing roles in context of the team. Leader is indetified . 2. Storming- conflict and confusion. Team members see themselves as individuals and will want to respond to the task in the manner that they would respond as individuals. Some may be reluctant to work as a team, while others may be resless to get through the team building activities. Conflict can arise. Formulate team rules that will guide team members in performance, interaction, decision making and how they accomplish their goals. 3. Norming- consolidation. As team members begin to work together, establish their roles, and help one another see the value in this, team cohesion develops. Members must appreciate one another's strengths and limitations. 4. Performing- teamwork and performance. When work is getting done and the team feels positive about it. Consensus building occurs when decisions are made.

You have been appointed as the leader of a team at your workplace. Identify 5 strategies you will use to increase the team's trust of you as a leader.

5 strategies I would use to build my team's trust in me as a leader include: Listening to feedback from members so they feel they have a purpose within the team and their opinion and expertise is valued; recognize a job well done and individual accomplishments from members; empower team members to make decisions as to what they think would be most appropriate to meeting the team goals; help resolve conflicts within the team in a fair and unbiased manner; and provide resources to help them accomplish individual tasks to build more confidence and strive toward our common goal.

What is the difference between a root cause analysis and a failure modes effects analysis?

A FMEA is an analysis done before an error occurs, a root cause analysis is done after an error occurs to ensure it doesn't happen again.

What are the benefits to an agency or organization of high level teamwork among its nurses?

A high level of teamwork among nurses leads to better patient outcomes and satisfaction, both among patients and team members. Nurses feel supported by one another, and learn from one another making them more knowledgeable productive employees. The better patient and nurse satisfaction is, the better the business aspect will fare for the agency and the less nurse turnover they will incur saving significant training costs.

What is a huddle? Provide an example of when a nurse might call a huddle and what would happen during that huddle.

A huddle is a short team meeting, usually 15 minutes or less, that allows a team to set objectives, share new information and plan next steps. An example would be a circulating nurse calling a time out before a surgical procedure to get all the surgical team members on the same page and set a shared mental plan. Everyone would introduce themselves and state their role, and the leader (nurse) would let everyone know any risks or possible complications.

Unsafe acts are categorized as violations or errors? What is the difference between a violation and an error?

An error is an action that doesn't go as planned, or the wrong action to take altogether, but it is not deliberate. A violation is deliberate, although not always malicious.

What techniques might a nurse manager use to increase staff feedback? Provide an example of one of these techniques.

A nurse manager could increase staff feedback by following up with any issues or problems that her staff may have. For example, if a nurse was having an issue with not having enough supplies, the nurse manager should follow up on the root of the issue and try to connect with the department responsible to rectify the problem.

What is a sentinel event? Provide two examples.

A sentinel event is an unexpected event involving death or serious physical or psychological injury or risk thereof. Some examples would be a patient losing the wrong body part in an amputation operation, or an object being left in a patient's body after an operation and causing an infection.

In addition to measuring structure, process and outcomes, what other foci should be included in developing an effective quality improvement program?

Accessibility- Assessment of access to care and who is unable to access care is an important measure of quality care. There are many factors that impact the accessibility of care. Accesibility also includes how services are received within a system and the outcomes of those services. The improvement of care requires that barriers to care be addressed. Safety of care environment- Adverse events are monitored by hospitals to assess the status of the care provided to minimize errors. Root cause analysis should always be performed to assess the causes of the error. Organizational polices and procedures set standards within the health care organization and utilizes evidence based practice to provide care for their patients. Standards provide a minimum requirement by which health care providers must adhere to. Continuity- QI should be continuous with no end. As problems are resolved and care is improved upon, the organizaions should then focus on new concerns and also review past problem areas to determine if improvement continues. Focus should be on continuous improvement.

What are barriers to effective coordination? What are strategies to promote effective coordination ?

Barriers to effective coordination include team members' lack of emotional intelligence and lack of understanding of their own collaborative role and the role of their fellow team members. Lack of communication regarding purpose and goals of patient care are also critical barriers. Effective coordination begins with effective leadership. Someone is needed to delegate responsibilites and make goals clear to fellow providers within the team. Evaluating and re-evaluating what is working and what is not is also necessary to promote effective coordination of patient care so everyone is on the same page regarding changes and updates on care.

Discuss the meaning of accountability in healthcare. As a nursing student you observe a physician, the Vice President of Nursing and the Dean of the School of Nursing making rounds. They enter your patient's room, but the Dean does not wash her hand. What is your accountability in this situation?

It is my responsibility to let the Dean know to wash her hands. I would pull her aside and not make it known to the physician, the VP of nursing, or the patient. It may be an intimidating situation, but being a patient advocate is going to be challenging and ethical dilemmas and ethical decisions are part of the responsibility of the registered nurse.

What is empowerment? Is it the same or different than power as a management strategy?

Empowerment is allowing team members the freedom to make some independent decisions regarding their actions and practice. It is different than power as a management strategy because when you empower people, there are others that lose their power over the actions of those that are being empowered. When people are empowered, those usually in power lose some of that power.

What is the purpose of debriefing? Provide an example of how you use debriefing in your clinical practice.

Debriefings are short meetings after a procedure of process where the patient care team sums up what happened, what went well and what can be improved. Debriefing between nurses is often called "getting report" to convey what happened during a shift.

What is a Failure Modes and Effects analysis and how does it impact the nurses on the unit.

FMEA is a tool that a method to evaluate a process for the purpose of identifying where and how it could fail and the parts that most need to be changed. This impacts nurses because it promotes effective leadership and team functioning and support, and moves toward a culture of safety as opposed to a culture of blame.

Discuss the Swiss Cheese model and how it related to errors in healthcare?

Failure of systems; one isolated error results in bad outcome due to holes. It relates to healthcare because one error leads to another without it being caught. An error quickly becomes catastrophic because opportunities to correct the situation are missed one by one. An example would be if a patient was given the wrong med dose, then vitals were supposed to be taken the next hour but a nurse or aide didn't have time so entered vitals from the previous entry, they were supposed to be on continuous pulse ox but it fell off, no one checked then they became hypoxic and died because of all the errors not being caught.

What is failure to rescue? Think back to Grace's story - what is an example of failure to rescue?

Failure to rescue is not recognizing complications or not activating appropriate interventions. An example from Grace's story of FTR was when the nurse was advised that Grace was in distress in her room after her surgery and was not promptly assessed.

Describe 5 barriers to effective communications.

Failure to speak up or clarify when a message is unclear. One must ask questions to know exactly what message the sender is trying to convey. Expressing aggressive opinions, which alienates and intimidates the listener and discourages feedback. Communicating information that is not accurate, like jumping to conclusions without knowing the ful scope of information. Disrespecting others by using profanity or destructive criticism severely limits effective communication. Not recognizing the opinions or information of others facilitates negative feelings and difficult communication.

Communication includes sender, message, receiver and context. Provide an example of how each of these elements may lead to miscommunication in the healthcare environment.

Feedback should not be described as something that is negative Positive feedback, what has been done well, is critical Simple clear language is always better. It is easy to make assumptions about communication Questions can be used to clarify and stimulate feedback. The sender may be the manager to staff nurse, and downward communication is not always understood correctly by the receiver. The message may have negative consequences for the receiver, such as a patient finding out they have a terminal illness, so the receiver may miss important elements of the message due to anxiety. The receiver may, in the case of downward communication, may see the exchange as an insult or a command, and will be biased toward the information. The context in which the communication is given may be inappropriate, such as in an aide passing important information to the nurse without it being understood or verified, and the nurse forgets to act on the message. This could have devastating consequences for patient care.

Discuss 3 reasons handoff communications are critical in the healthcare setting.

Handoff communication is critical in the healthcare setting. Healthcare teams can prevent errors, mitigate problems related to human factors, and enhance safety for patients. Quick, efficient and complete information prevents errors, asking the right questions and using techniques such as SBAR lessen the chance of human factors contributing to ineffective communication. When all team members are on the same page with patient care safety is greatly increased.

You have just learned that your patient received a double dose of blood pressure medication and experienced a severe drop in blood pressure that made him very dizzy. The care plan was to have the patient up and walking about today. However, because of the overdose and its impact, the patient will not be able to walk with the therapist as planned. The result may be at least one additional day in the hospital. You do not yet know what contributed to the error, but you're confident that this is not a progression of the patient's underlying condition of Meniere's disease (periodic episodes of dizziness). What do you tell the pt?

I would be transparent and tell the patient honestly what happened. I would convey to them that there would be an investigation into exactly what happened that allowed the medication error to occur, and steps will be taken to ensure it wouldn't happen again, to them or another patient. I would like to update they and their family with information and allow an open line of communication.

ou administer the pain medicine at 9 am. At noon the nursing assist tells you this patient has been disoriented and combative since receiving the new medication. You review his medication administration record and you realize with horror that, in your hurry, you miscalculated the conversion from one narcotic to another and accidentally applied the range of morphine dosing to the hydromorphone, resulting in an almost sevenfold overdose of medication to an elderly patient. The patient had thrashed around so much that his drains filled with copious amounts of blood and had to be emptied multiple times . Aside from relief that you didn't sedate the patient to the point of not breathing, you are suddenly furious with yourself - for giving the medication. You stop long enough to reflect on what has happened. What is your priority action in this situation?

Immediately assess the patient, then let your charge nurse/supervisor know what has happened.

Describe five individual factors that contribute to errors in the healthcare setting. What can you do in your individual practice to control the negative impact of these factors and protect your patients?

Individual factors that lead to errors include multitasking, fatigue, over-confidence, ineffective communication, and not following protocol. Multitasking can lead to mistakes because there is no focus on a particular task or completing it correctly. Fatigue does not allow for adequate concentration. Over-confidence can lead to an attitude that "I can do no wrong" so orders/procedures are not taken seriously or double checked, which can lead to not following protocol, which often can happen if one is multitasking or in a hurry to complete tasks. Ineffective communication can lead to errors because all providers involved in a patient's care need to be working in a team and updated on status at all times. I can make sure I get enough sleep and try to make my life outside my work as satisfying as possible. I'll try to never think I am too good to make a mistake, I will allow time for completion and concentration on the task at hand, because a patient's life may be on the line, and for that reason, and also to protect myself, I will follow my facility's protocol for policies and procedures. I will try to communciate effectively and without ego or bias with other members of my patient's healthcare team to minimize errors from lapses in communication.

What are the elements of competent nursing practice?

Individual factors, nature of work factors, and organizational unit factors. • collaboration: the RN collaborates with other healthcare providers, consumers and family members. Participative management and building collaborative relationships. • communication: embrace effective communication techniques, express ideas clearly and concisely. • education: the RN attains knowledge and competence and reflects it on his/her practice. Nursing is a life-long learning profession, should encourage professional development • environmental health: practice in an environmentally safe and healthy manner. Leadership related to wellness and self-care activities. • ethics: the nurse must practice ethically, with integrity, honesty, responsibility, accountability, credibility. • evidence based practice and research: the RN integrates evidence and research into practice. • leadership: leading self, leading others, and leading the organization. • professional practice evaluation: a RN evaluates his/her own practice in relation to professional/organizational practice standards and guidelines. • quality of practice: RN contributes to quality of nursing practice through creativity, innovation and quality improvement. • resource utilization: RN utilizes appropriate resources to plan and provide care that is safe, effective and financially responsible.

Quality measures include structure, process and outcome measures. Give an example from a clinical setting of a measure used to monitor each of the types of measures.

Measures of structure include characteristics of policies and personnel of the organization in question such as nurse/patient ratio. A process measure refers to whether the patient received quality care, such as the interpersonal interaction between the patient and provider, or a foot exam in a diabetic patient. Outcome measure example is a reduction in a patient's pain or a timely reduction in blood pressure readings as a result of good care.

There are different type of quality problems in patient care situations. Define/give an example of the following problems:

Misuse consists of avoidable mistakes that keep patients from receiving full potential benefit of a service. An example would be prescribing antibiotics for a viral infection, thereby missing an opportunity to address the actual problem. Error of planning is choosing the wrong plan to achieve a goal. An example would be if a patient needs an MRI but only an x-ray is ordered and misses a diagnosis. Underuse is the failure to provide a service that would have led to a favorable outcome. For example, an insurance company will not pay for a name-brand med that the patient needs, so they instead get a generic version that does not work for them.

Identify four different types of team found in multi-hospital organizations. Give an example of when each type of team is used.

Multidisciplinary teams-professionals of different disciplines assess and treat patients then share information with each other, this may be used for a diabetic amputee, with RNs, physical and occupational therapists, surgeon and endocrinologist treating the patient Finkelman, p. 336 Nursing Teams-may consist of an RN, LPN/LVN and UAP all contributing to patient care, such as in a long term care facility Finkelman, p. 335 Formal team-created specifically by managers of an organization. An example would be a QI committee Finkelman, p. 329 Informal team-self formed groups whose members share common values or experiences; not recognized by an organization. An informal team may form a support group for those within a unit that has emotionally difficult job dutes such as PICU

Discuss three of the recommendations in the Future of Nursing Leading Change, Advancing Health report.

Recommendation from the Advancing Health report states that nursing associations, nurse education programs and nurses themselves should take responsiblity for leadership to advance health and wellness. They suggest nurses be trained to fill leadership roles in a varieity of influential settings such as public, private and governmental health care organizations. Another recommendation is for nurses to engage in continuing education. Current nurses as well as students should be taught the importance of continuous learning to keep up with changing heathcare landscapes and knowledge to provide the best care to a diverse and ever-changing patient population. Nursing education programs should be continuously assessing and evaluating if they are providing current education opportunities that are useful in real world practice. Recommendation 5 states that the number of doctorate prepared nurses should double by 2020. This will ensure diversity in nursing and add cadre to nursing faculty and education.

What are the similarities and differences between: Teamwork. Shared governance. A working group. Collective individuality Self-directed work teams.

Teamwork is needed to achieve an objective. Teamwork plays a role in shared governance, which means each team member has a personal responsibility and accountability in decisions made that affect functioning and goals, not just team leaders. Teamwork means sharing this responsibility together to achieve a common goal. A working group is part of a team that bring team members of different disciplines and skills together to achieve a specific goal in getting the patient to wellness. Collective individuality means taking personal ownership and responsibility for your role in the collaborative process. Self-directed work teams center around patient satisfaction; for example although there is collaboration, it is not focused on team members, it is patient focused, catering to their needs. SDWT roles change with patient needs but have specific boundaries and responsibilities.

Describe how technology impacts the safety of the patient in the healthcare environment? Does the use of technology enhance safety or introduce the potential for lapses?

Technology both enhances safety and introduces a new set of circumstances which can cause lapses and errors. IV medication pumps and CPOE systems are two examples of how technological systems can both help and hurt patients. The IV pump automatically calculates the rate of infusion, thereby reducing the chances of the nurse making a human error and calculating the wrong rate, yet if there is a problem and the pump is beeping and the nurse ignores it (alarm fatigue) it could cause a new problem. The same is true for the CPOE. It can alert the nurse to interactions and allergies, but if the nurse learns to use workarounds to save time when navigating through the system, it could cause a potentially catastrophic error.

What is the ANA definition of collaboration and give an example of the application of this definition in your nursing practice.

The ANA defines collaboration as the recognizing of the expertise of other professionals, and the openness to include them in patient care and defer to them when appropriate in achieving common goals for a patient through a common mission. An example would be physical therapy. After a hip replacment surgery many physicians and physical therapists want the patient up and walking within 24 hours. If I cared for a patient such as this, I would respect and heed the advice of these professionals, as I would expect they would respect my nursing judgment and opinion on decisions regarding the patient.

Over the past year your unit has experienced an increase in medication errors and in infections. What are 5 factors to investigate in the search for the cause of these increases?

These factors can include: Institutional Organizational and management Work Environment Team Individual staff member Task Patient

What is the relationship between the joint commission and the Quality process in Healthcare?

The Joint Commission is directly involved in safety/quality issues as an accrediting organization. Since the IOM started reporting on errors and safety in healthcare in 1999, the Joint Commission has enacted initiatives that are supported by nursing organizations such as the ANA that are designed to inform providers and patients alike to the dangers of mistakes and errors in healthcare. They have also created goals that organizations must meet to be designated as an accredited organization.

Explain the PDSA (Plan, Do, Study, Act) model of quality improvement to a new student who is just beginning their study of nursing.

The PDSA cycle takes place during the pilot phase of the 4 step quality improvement project. This cycle is a model used to test and improve a change that you want to implement that will improve a process or procedure. The plan is when you ask the who, what, when, where, and why of the change. This is also the time to set an objective and plan for data collection. The Do phase is when the change is carried out and documented, what went wrong and what worked and record data on it. The study phase is to summarize how the change went, if it went as predicted, and analyze the data. You may have to do this more than once, tweaking the process and the change depending on the study. Once this goes smoothly and data is showing that improvement is happening, you can implement your idea/change on a larger scale.

What is the difference between a culture of safety and a culture of blame.

The day shift nurse would see that a PRN pain med has just been given at 0600 and before that at 0400, and it wasn't due to be given again until 0800. The patient is now experiencing a respiratory rate of 8. In a culture of safety, the nurse manager and the QA team would address what could have gone wrong, did the system incorrectly show when the med was last given? Was the unit understaffed and the nurse was covering another nurse's patient? Had this nurse been working longer than 12 hours? Was there a miscommunication between staff members? In a culture of blame, this nurse would fill out an incident report and subsequently be fired.

What are the first 3 questions asked in conducting a root cause analysis? What is involved in conducting a root cause analysis?

The first 3 questions asked in conducting root cause analysis are: 1. What happened?; 2. How did this happen? 3. How could have it been prevented? Root cause analyses can recognize correctable systems failures. Focusing on system vulnerabilities and causes rather than blame is the goal of root cause analysis. An RCA team is formed from various members of the health care team and administration, and possible community members. Using a framework such as Charles Vincent's seven contributory factors, the team identify direct and contributory causes. The RCA team then creates a fishbone diagram or flow chart and develops and writes causal statements.

Identify 5 factors that might result in the nurse making a medication error.

The nurse's unit is understaffed, and she has been assigned too many patients to provide the safest care; she is busy and rushed. Similar packaging on completely different medications. The nurse may misread a handwritten order from a physician for one patient, when a different name was actually on the form. The nurse is on hour 13 of work waiting for the nurse coming on for the next shift, and miscalculates the order and gives a patient 3 tablets instead of 2. The nurse administered 30 units of insulin when she meant to administer 3, as she read a 0 instead of a U on the order because she was worried about her teenage daughter whom she just found out was suspended from school.

Peter, a patient with atrial fibrillation (heart arrhythmia), is placed on warfarin, a blood thinner, by his cardiologist. Peter goes to clinic weekly to have his INR, a measure of how thin his blood is, checked. One week he does not get a call after his bloodwork, and the week after he is admitted to the hospital with a bleeding ulcer. His INR that night is 6, indicating his blood is dangerously thin. A team conducts an RCA. One root cause the team identifies is that the cardiology clinic does not have a specific method to make sure they reach all patients with INRs and communicate their results by the end of the week. Write the best recommended action statement for this situation?

The nurse/nurses at the cardiology clinic will generate a list of all the INR results of patients who had this lab done on that specific day and enter a note with a current phone number into the patient's chart that he/she has personally spoken with the patient and they are aware of their INR level. The physician'smedical assistant will be responsible for going over this list at the end of the day and following up with patients who have not been spoken with directly. After 2 weeks, 100% of patients should be personally spoken with within 2 business days to follow up on their INR results.

What are the phases of the quality improvement process? Think of a basic process from your everyday personal or professional life that you would like to improve - for example, you want to get more exercise, you want to get more sleep, or you want to eat healthier food. Apple the phases of the qi process to improve this process.

The phases of the quality improvement process are innovation, pilot, implementation and spread. I would like my family to eat healthier meals and I would like to implement this improvement. My idea isn't really innovation but benchmarking, since I know people who make healthy meals for their familites. I will pilot the plan just for one meal when I am usually home, which is dinner on the weekend, to see if I can make time to cut and chop vegetables and make meals from scratch. I will use short PDSA cycles to experiment with time constraints and what my children will eat. Once I get find some recipes that work within my schedule and my family's taste, I will implement them with other weekend meals like lunch. Once this is successful, I will spead the change by using these recipes on the weeknights so 90% of the time my family will be eating nutritious meals for lunch and dinner.

What is the primary goal of quality improvement in healthcare settings? What are some secondary goals of the QI movement?

The primary goal of quality improvement in healthcare settings is safety. Other goals include effective (evidence-based) care, patient-centered, timely, efficient, and equitable care.

Based on the findings of the study by Choi et al (2013), what are critical elements in mitigating risk in the clinical environment?

This study found that critical elements that mitigate risk in the clinial environment are the role seasoned nurses play, filling gaps for novice nurses, working as a team with them to help them in complex situations and avoid near misses. These nurses use their clinical intuition that new nurses have not developed yet for providing proactive care. The study also found that, as previously stated, nurses act proactively to prevent anticipated harm. Sick patients are vulnerable to institutional risks, and nurses advocate for them, protecting them from harm and undesirable outcomes.

You are reviewing a patient's records and notice that a recent chest x-ray report (from an x-ray taken when she was recently hospitalized for pneumonia) discusses a mass in the patient's left lung. However, no mention of this mass is made in other documents, and it becomes clear that the patient has not been told about this mass, which may be cancer. What should go in this patient's medical record about the incident?

This was a breakdown in communication between team members. I would document in the chart that the physician/radiologist, needs to review this x-ray immediately, flag it as urgent, if possible. Then verbally verify that the provider is aware of this, and document that as well.

ow has the Institute of Medicine report, To Err is Human (1999) impacted healthcare?

To Err is Human (1999) signaled the shift in healthcare that an extraordinary high number of errors were occuring, and the reason for this isn't because our health care practitioners were incompetent or uncaring, but the framework of the system in which we provide care is fundamentally flawed and makes providers more susceptible to sometimes catastophic mistakes. This caused the IOM to begin to question the processes in the way care is provided and what we can do to make the system safer for patients.