Safety/Prevention

The Patient Safety and Quality Improvement Act

2005 act that mandated voluntary and anonymous safety and quality reporting systems on the federal level and protects individuals who report information to patient safety organizations

1. Identify patients correctly 2. Improve staff communication 3. Use medicines safely

2017 National Patient Safety Goals:

1. Identify individuals served correctly -- use 2 identifiers 2. Use medicines safely 3. Prevent infection -- proper hand hygiene 4. Identify individuals with safety risks

2018 National Patient Safety Goals:

1. Patient-centered care 2. Quality improvement 3. Evidence-based practice 4. Teamwork and collaboration 5. Safety 6. Informatics

6 competencies of the QSEN:

Just culture

A culture which fosters mutual trust Fair treatment and open communication is the goal Seeks not to place guilt or blame on any staff member Reporting is CONFIDENTIAL -- first goes to a safety committee

c

A home health nurse is teaching an older adult client who has returned home after discharge from the hospital about injury prevention. Which goal would be appropriate to include in this client's plan of care? a. The client will take the prescribed medication as desired b. The client will make uninformed choices when addressing health issues c. The client will demonstrate an understanding of all limitations d. The client will establish a buddy system

d **be particularly attentive of the path to the bathroom

A nurse manager is assessing the hospital environment in order to decrease the risk for client falls. Which is the best intervention to decrease the risk of client falls? a. Keep the call button within reach at all times b. Read label directions c. Keep electrical cords under the bed d. Clean the environment of clutter

Prevention

Action taken to prevent the occurrence of an event or disease or to minimize its effect after it has occurred Actions span primary, secondary, and tertiary levels

Secondary prevention

Activities are aimed at early disease detection and treatment to prevent the progression of the disease and its associated symptoms

National Patient Safety Initiatives

Aim to foster collaboration with healthcare facilities, government agencies, physicians, nurses, and healthcare clients to enhance patient safety and quality of care Achieved through education, dissemination of better safety practices and resources, risk management strategies, and reducing medication errors

Latent errors

All the errors that create problems and set us up for having an active error

reduced

Although the number of injuries and fatalities are ______________ (increased/reduced) compared to toddlers, the most common cause of injury and fatalities in preschoolers is generally the same

Restraints

Any device or medication intended to protect the client from injuring self or others through partially or fully limiting the client's mobility

Physical restraints

Any manual method, material, device, or equipment attached to client's body in order to restrain them Examples include: - limb restraints - belt restraints - safety strap body restraints - mitt restraints - hand restraints - wheelchairs with stationary lap trays - bed rails - geri chairs

Primary prevention

Avoids development of disease as much as possible and promotes healthy living

1. User-centered design -- builds on human strengths and avoids human weaknesses 2. Avoid reliance on memory -- standardize equipment and simplify key processes 3. Attend to work safety 4. Avoid reliance on vigilance 5. Train concepts for teams 6. Involve patients in their care 7. Anticipate the unexpected 8. Design for recovery 9. Improve access to accurate, timely information

Basic concepts in patient safety include:

Tertiary prevention

Begins after a condition is treated and stabilized or recognized as uncurable. Includes the restoration of function and decrease of complications of an established disease. If restoration to the previous level of function is not possible, care focuses on controlling symptoms and promoting the highest quality of life possible. Rehabilitation and palliative care are included in tertiary prevention.

secondary primary

By implementing health promotion strategies, the nurse has an opportunity to step out of the ___________________ (primary/secondary) prevention area and into the __________________ (primary/secondary) prevention area

Medication errors

Client either receiving the wrong medication or the wrong dosage, and also administering the wrong formulation or the correct medication at the wrong time

No disease --> ONSET --> asymptomatic disease --> CLINICAL DIAGNOSIS --> clinical course

Continuum of a disease:

voluntary mobility

Criteria for qualification as a restraint include whether or not implementation of a device was __________________, as well as the degree to which its use limits the client's freedom of ______________.

Secondary prevention

Detect and then treat identified injuries and diseases early so that they can be cured or their associated symptoms and complications can be prevented or limited

National Patient Safety Goals

Developed by the Patient Safety Advisory Group that evaluates safety concerns and evaluates which ones will have maximum impact and usefulness for the minimum cost

Near miss

Error that doesn't happen, but only due to nurse's vigilance -- notices something that would cause harm to patient and changes it

Sentinel events

Errors that result in SERIOUS injury or death Signal the need for an immediate response, analysis to identify all factors contributing to the error, and reporting to the appropriate individuals and organizations to guide system improvements EX: wrong side surgery

Adverse events

Errors that result in injury or harm May or may not have serious consequences EX: wrong dose of Benadryl -- may just cause more drowsiness

1. Correctly identify patients 2. Improve staff communication 3. Use medicine safely 4. Prevent infections 5. Prevent surgical mistakes 6. Identify students at risk for suicide

Examples of national patient safety goals:

Tertiary prevention

Focus is on reducing complications or further deterioration of disease

Safety

Freedom from accidental injury Ensuring this involves the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur

1. Primary prevention 2. Secondary prevention 3. Tertiary prevention

Healthcare delivery can be classified by the type of services offered which include:

Use at least 2 ways to identify patients For example, use the patient's name AND date of birth to make sure that each patient gets the right medication and treatment

How can a nurse help identify patients correctly?

Get important test results to the right staff person in a timely manner

How can a nurse help improve staff communication?

Before a procedure, label medicines that are not labeled Record and pass along correct information about a patient's medicines

How can a nurse help use medicines safely?

1. National Center for Patient Safety 2. Mandatory and voluntary reporting systems 3. Role of consumers, professionals, and accreditation groups 4. Building a culture of safety

IOM Patient Safety Recommendations include:

promotion

Implementation focuses on wellness _______________, including client education and screening

strengths, weaknesses

Improving safety requires respecting human abilities by designing processes that recognize human ____________ and ___________________.

Malignant cancers

In middle adults, for the FIRST time, unintentional injuries are not the leading cause of death. What is?

Health-care associated infections

Infections that occur while a client is being treated for another condition

1. Falls 2. Restraints 3. Healthcare-associated infections 4. Wrong-site surgery 5. Medication errors 6. Readmission/diagnostic errors

Injury prevention in the clinical setting is important in these categories:

Tertiary prevention

Involves restoring function and decreasing disease-related complications of an already established disease

systems people

Latent errors are done by ____________, whereas active errors are done by _____________.

failure

Latent errors set us up for ____________!

ineffective

Less restrictive measures must be implemented first and determined to be _________________ before the use of restraints

third **Only after heart disease and cancer**

Medical errors is the _________ leading cause of death in the US

Reason's Swiss Cheese Model of Accident Causation

Model that has 4 factors: 1. Blunt end -- latent failures (minor factors that interact to lead to an error) 2. Error-producing conditions 3. Sharp end -- active failures (i.e. slips, lapses, mistakes, violations) 4. Patient safety incident **Steps 1-3 are stopped at one point and checked by someone to prevent #4 error

Motor vehicle crashes

Most injuries in the young adult population are caused by what?

1. Providing health education at every opportunity 2. Evaluating and screening clients to identify prevention opportunities such as immunizations 3. Promoting wellness in the community by organizing and participating in community events such as health fairs

Nurses can participate in health promotion by:

healthy wellness

Nurses should teach clients how to remain ___________, thus preserving _______________

Transparency

Open communication and information to patients and families about care, including adverse and sentinel events

Chemical restraints

Pharmacologic agents that are administered to control hyperactive behavior in agitated clients Examples include: - sedatives - hypnotics - neuroleptics - antianxiety medications

systems

Preventing errors and improving safety require a _____________ approach to the design of processes, tasks, training, and conditions of work in order to modify the conditions that contribute to errors

Primary prevention

Prevention type in which service focuses on health promotion and illness prevention

Secondary prevention

Prevention type in which services include the diagnosis and treatment of disease

Tertiary prevention

Prevention type that consists of the restoration of health following an illness or accident and includes rehabilitation and palliative services

Quality and Safety Education for Nurses (QSEN)

Program with the goal to more effectively prepare future nurses with practical experience and the knowledge, skills, and attitudes necessary to provide better quality and safety in healthcare Says that every graduating nurse should have mastered 6 competencies Each competency is associated with expectations of certain knowledge, skills, and attitudes to demonstrate understanding as well as proper implementation and appropriate values

Informatics

QSEN competency in which nurses use information and technology to further client care and safety Ensures client information is protected by using appropriate system safeguards and practices As information technology becomes further integrated into medicine, nurses' input is an essential part of the design process

Quality improvement

QSEN competency in which the nurse constantly monitors client care and safety in order to improve the methods being employed Adverse events must be monitored and reported so they can be tools for learning in similar situations in the future and catalysts for improvements in quality and safety

Teamwork and collaboration

QSEN competency that allows nurses to work effectively with other departments in order to provide quality client care Nurses are held accountable for their own participation as team members and must be able to engage in conflict resolution Because treatment often involves multiple departments and 24 hour care, _____________ across departments and shifts is necessary for optimal care

Patient-centered care

QSEN competency that involves the clients in all aspects of care, recognizing the individual needs and values of each client Recognizes the need to respect the client's own experience and expertise Clients are partners in their care, and thus their perspectives, beliefs, and culture need to be taken into account during their care

Safety

QSEN competency that minimizes the risk of dangerous or harmful situations involving clients and other healthcare professionals Acts to reduce the possibility of healthcare-associated infections and the possibility for errors Activities such as knowledge sharing and error reporting must be taken seriously to improve _____________

Evidence-based practice

QSEN competency that requires nurses to recognize limits of his or her own knowledge and to know how to access current evidence to gain more insight and information Medicine is evolving and changing every day, and thus current medical findings must be monitored for the possibility of improved care

Wrong site surgery

Refers to surgery performed on the wrong client, the correct client but the wrong body part, or the correct client but the wrong surgery

b

Several nurses are discussing the Joint Commission's National Patient Safety Goals during a staff meeting. Which goal improves the effectiveness of communication among caregivers? a. Conduct a verification process to confirm the correct procedure b. Transmit test results in a timely manner to the appropriate staff member c. Review a list of look-alike/sound-alike drugs used in the organization d. Use the client's room number as an identifier

TRUE

T or F: "Error" that resulted in patient harm was not a property of health care professionals' competence, good intentions, or hard work. Rather, the safety of care—defined as "freedom from accidental injury"—is a property of a system of care, whether a hospital, primary care clinic, nursing home, retail pharmacy, or home care, in which specific attention is given to ensuring that well-designed processes of care prevent, recognize, and quickly recover from errors so that patients are not harmed

TRUE

T or F: 47% of adults have at least one major risk factor for heart disease or stroke (i.e. uncontrolled high BP, uncontrolled high LDL, current smoker)

FALSE

T or F: All errors result in injury or harm

TRUE

T or F: By implementing a mandatory, voluntary reporting system, it encourages the growth of voluntary, confidential reporting systems so that practitioners and health care organizations could learn about and correct problems before serious harm occurs

TRUE

T or F: Healthy People 2020 listed the following goals: 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death 2. Achieve health equity, eliminate disparities, and improve the health of all groups 3. Create social and physical environments that promote good health for all 4. Promote good quality of life, healthy development, and healthy behaviors across all life stages

TRUE

T or F: In nursing homes, 50-75% of its residents fall every year

TRUE

T or F: Med errors injure at least 1.5 million Americans annually

TRUE

T or F: Nurses assess and screen clients for potential safety hazards -- such as exposure to toxins, an increased risk of falling due to medication or age, motor vehicle crashes, heart disease, or cancer -- and then provide the client with information on how to avoid, prevent, or treat these hazards

TRUE

T or F: Over 30% of adults age 65+ fall every year

TRUE

T or F: Parents introduce risks themselves even before conception through genetic means, environmental exposure, and lifestyle choices. For example, errors in cell division, chromosomal abnormality, radiation, Rh factor incompatibility, viral or parasitic pathogens, teratogens like drugs/caffeine/tobacco, maternal age

TRUE

T or F: Per year, there are 1.7 million people infected with HAIs and of those 100,000 people die

TRUE

T or F: Responsibility for taking action could not be borne by any single group or individual and had to be addressed by health care organizations and groups that influence regulation, payment, legal liability, education and training, as well as patients and their families

TRUE

T or F: Restraints should NEVER be used as a form of punishment, as a convenience measure, to prevent clients from leaving, to make a client comply with the plan of care, etc

TRUE

T or F: Simply calling on individuals to improve safety would be misguided as blaming individuals for specific errors

TRUE

T or F: There are on average 98,000 hospital deaths from medical errors per year

TRUE

T or F: Two types of cognitive tasks that may result in errors in medicine: 1. Occurs when people engage in well-known, oft-repeated processes, such as driving to work or making a pot of coffee 2. Tasks that require problem solving are done more slowly and sequentially, are perceived as more difficult, and require conscious attention, such as making a differential diagnosis or readying several types of surgical equipment

TRUE

T or F: Use of restraints may result in injury or death

TRUE

T or F: When an error occurs, patients should be told what happened and those involved should take responsibility, apologize, and explain how the organization will respond, and how it will prevent future events.

TRUE

T or F: You can prevent communication errors, such as hand off errors, by using the say-back method, similar to the teach-back method

Primary prevention

Take action to prevent disease in generally healthy people and populations Give people tools that empower them to improve their own health through positive actions such as smoking cessation

1. Right drug 2. Right dose 3. Right client 4. Right route 5. Right time 6. Right documentation

The 6 rights of medication administration are:

1. PREVENTING the development of chronic diseases (~primary prevention) 2. DETECTING chronic diseases early and slowing their progression (~secondary prevention) 3. MITIGATING complications of chronic disease to optimize quality of life and to reduce demand on the health care system (~tertiary prevention)

The CDC priorities for chronic disease include:

Errors

The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

sharp

The following are examples of sharp or blunt end factors? 1. Administration of the wrong dose of a medication that is fatal 2. Mishap during surgery

blunt

The following are examples of sharp or blunt end factors? 1. Equipment design or maintenance 2. Working conditions 3. Design of processes so that too many handoffs occur 4. Failures of communication

Primary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. Educate individuals, families, and populations on topics such as the importance of nutrition, exercise, dental hygiene, prenatal care, immunization, and smoking cessation 2. Educate employers and employees about occupational safety as well as avoidance of occupational hazards 3. Improve environmental sanitation and provide adequate housing and nutrition (i.e. removal of lead from housing units)

Tertiary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. Giving beta blockers after a myocardial infarction

Primary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. Immunizations 2. Folate 3. Exercise 4. Seatbelts 5. Washing hands

Secondary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. Perform risk assessments for healthy people who have risk factors for specific diseases such as coronary artery disease and diabetes; then work with the client to develop and implement a risk reduction plan 2. Encourage regular dental, vision, and medical screening examinations for children and adults 3. Teach clients to perform self-screening examinations such as breast and testicular examinations 4. In all settings, develop and implement care plans to treat clients' illnesses and injuries (i.e. administer medication and treatment regimes) and prevent complications (i.e. turn, position, and exercise clients to prevent pressure ulcers and deep venous thromboses); ensure adequate rest, food intake, and fluid intake to promote healing and promote fecal and urinary elimination

Tertiary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. Refer a client with a new urostomy to an RN ostomy management specialist to learn how to care for and improve life with an ostomy 2. Refer a client with diabetes to a registered dietician for education on how diet can affect the complications of diabetes 3. Refer individuals with severe or chronic pain to a pain specialist to manage pain with an appropriate medication regimen and/or alternative treatment methods

Secondary

The following are examples of what level of prevention (primary/secondary/tertiary)? 1. SCREENING!!

a **NEVER leave children unattended in bathtub for risk of drowning

The home health nurse is talking with the parent outside the bathroom door while the toddlers are playing in the tub. Which client statement would require further safety teaching? a. "Why don't we talk in the living room?" b. "Let me get the children out of the tub so we can talk." c. "I do not like to leave the children alone in the bathroom." d. "I often bathe the children together."

c

The nurse is caring for a client who will be discharged on a new blood pressure medication which increases the risk of orthostatic hypotension. Which should the nurse include in the discharge teaching to decrease the risk of injury at home? a. Encourage appropriate lighting b. Provide a bedside commode c. Rise slowly when getting up d. Monitor activity tolerance

d

The nurse manager is assessing safe medication administration in preparation for the Joint Commission's (TJC) visit to the hospital. Which observed action is NOT recommended according to the TJC's National Patient Safety Goals? a. Labeling all medicines that will be administered to the client appropriately b. Using extra caution with blood thinners c. Taking care when recording client medicine information d. Allowing the client to keep home meds at the bedside for use while in the hospital

Health promotion

The process of enabling people to increase control over and to improve their health

more

There are _________ (more/less) accidents, falls, and playground injuries in school-age children than in preschoolers

Primordial prevention

This type of prevention seeks to avoid emergence and establishment of social, economic, and cultural patterns of living that contribute to an elevated risk of disease Purpose: decrease a population's risk to disease Occurs before primary prevention

trust

Timely, honest communication with patients and families helps restore ________.

Primary prevention

Tries to prevent disease from occurring in the first place by removing disease factors

Secondary prevention

Trying to detect disease that is already there, but is asymptomatic; trying to do early detection and treatment to prevent it from progressing to serious nature

1. Catheter-associated UTIs (most common) 2. Health-care associated pneumonia 3. Surgical site infections 4. Intravascular catheter-related infections 5. Cdiff associated infection

What are some examples of HAIs?

1. Minnesota Fall Prevention Initiative -- developed to combat the increasing risk of falls in the elderly population by providing information to the general public and healthcare professionals regarding home safety, medication safety, and promoting safe movement 2. Mass in Motion -- developed to decrease the number of adults and children who are overweight/obese and decrease the prevalence of chronic disease related to unhealthy eating/lack of exercise

What are some examples of community and local initiatives?

1. Premature birth* 2. Congenital malformations* 3. Infection 4. Asphyxia 5. Disorders related to short gestation, preterm delivery, or low-birth weight 6. Maternal complications of pregnancy/complications related to the placenta, cord, and membranes

What are some neonatal risks for injury?

1. Remove obstacles from walking paths 2. Keep frequently used objects within reach 3. Ensure rooms are well lit 4. Clients should wear shoes with soles that provide good traction 5. Assess client's vision 6. Utilize side rails 7. Apply physical restraints when necessary 8. Be aware of the client's medication regimen because side effects may include dizziness or drowsiness

What are some nursing interventions that might be applicable to try to reduce falls?

1. Poor infant nutrition* 2. Neglect and/or abuse of the infant* 3. Poor maternal nutrition 4. Teratogen exposure 5. Obesity 6. Pathogens 7. Advanced maternal age 8. Preeclampsia 9. Placental complications and cord issues

What are some perinatal risks for injury?

1. Poor prenatal nutrition 2. Exposure to toxins such as drugs, alcohol, and tobacco

What are some prenatal risks for injury?

1. High BP 2. Tobacco smoking and secondhand smoke exposure 3. High BMI 4. Physical inactivity 5. Alcohol use 6. Diets low in fruits and vegetables and high in sodium and saturated fats

What are some risk factors for global disease trends?

1. Motor vehicle crashes (leading cause of death) 2. Poisoning -- mostly due to drug exposure 3. Drowning 4. Suicide 5. Being unintentionally struck by or against something 6. Unintentional falls 7. Overexertion 8. Being a motor vehicle occupant 9. Having a cut or puncture 10. Nonsexual assault

What are some risks for injury in adolescents?

1. Unintentional injuries such as suffocation as a result of co-sleeping 2. Traumatic brain injury from falls and having a soft head 3. Complications during delivery 4. Congenital anomalies and short gestation

What are some risks for injury in infants?

1. Malignant cancers -- leading cause of death 2. Heart disease -- second leading cause of death 3. Drug overdose/bad drug interactions

What are some risks for injury in middle adults?

1. Unintentional falls 2. Chronic illnesses (CV disease, cancer, diabetes)

What are some risks for injury in older adults?

1. Choking 2. Drowning 3. Motor vehicle accidents 4. Fires/burns and suffocation ALSO: (nonfatal) 5. Unintentional falls 6. Being unintentionally struck by or against something 7. Bites/stings 8. Foreign bodies lodged in their throats

What are some risks for injury in preschoolers?

1. Motor vehicle crashes 2. Drowning* 3. Fire/burns and suffocation 4. Unintentional falls 5. Being unintentionally struck by or against something 6. Bodily cuts or piercings 7. Bites/stings 8. Overexertion 9. Bicycle accidents*

What are some risks for injury in school-age children?

1. Choking (on toys) 2. Drowning 3. Motor vehicle accidents or being pushed/hit/shaken -- their small size and developing bones 4. Fires/burns and suffocation

What are some risks for injury in toddlers?

1. Unintentional injuries -- with almost half due to poisoning by drugs or narcotics 2. Motor vehicle accidents 3. Malignant cancer 4. Heart disease 5. Suicide 6. Homicide

What are some risks for injury in young adults?

1. Inadequate client assessment/care planning 2. Communication failure 3. Inadequate medical record review 4. Multiple procedures on multiple body parts of a client performed during a single operation 5. Failure to include the client and family when identifying the correct operation site 6. Failure to clearly mark the correct operation site 7. Failure to recheck information before starting the operation

What are some things that can contribute to wrong-site surgery?

Recognizing and implementing actions to prevent error

What has the greatest effect in preventing errors?

Unintentional injuries

What is the leading cause of death among children of all ages?

Unintentional falls

What is the leading cause of injury in the older adult population?

Falls

What is the most common cause of nonfatal injuries and leading cause of injury death in older adults?

Inconsistent hand hygiene by healthcare workers

What often leads to HAIs?

Now we use few indwelling catheters because the longer the catheter is in, the more increased risk of UTI and delirium

What steps have we taken to decrease the prevalence of catheter-associated UTIs?

controlling

When restoration to the previous level of functioning is not possible, care is focused on __________________ symptoms and promoting the highest quality of life

Adolescents

Which age group has the highest rate of injury during sports and play and the highest rates of sports/recreation traumatic brain injuries?

Secondary

Which type of prevention has a focus on early detection and prompt interventions to alleviate health problems and prevent complications?

Primary

Which type of prevention has a focus on health promotion and protection from specific disease?

Tertiary

Which type of prevention has a focus on restoring and rehabilitating the patient?

Tertiary

Which type of prevention has a purpose to allow the patient to return to their optimal level of functioning?

Primary

Which type of prevention has a purpose to decrease an individual's risk to disease?

Secondary

Which type of prevention has a purpose to identify patients as early stage and limit disability?

The injury is thought to be due to a medical intervention, not the underlying condition of the patient

Why are adverse events preventable?

Screening

________________ is a means of early detection of diseases such as hypertension and vision or hearing problems