NUR3816 Exam 2
Health promotion
- Approach behavior - Not disease oriented - Expand positive potential for health
Associate Degree RN (ADN)
- Nominally 2 years in length - Located in community colleges - Earn AD, AS, AAS degree - Traditionally a technical orientation to bedside care
Charismatic leadership
- emotional relationship between the leader and group members - inspires others by obtaining emotional commitment - followers have faith and belief in leaders abilities
Transactional leadership
- traditional manager focused on the day-to-day tasks of achieving organizational goals - relationship is based on exchange for some resource valued by the follower
How long does the facility have to report adverse events?
15 calendar days
Factors that inhibit learning:
Emotions Physiological factors Cultural and spiritual factors Health literacy
National Institute of Nursing Research (NINR)
Establishes in 1986, elevated to an institute at NIH in 1993 NINR's five strategies to advance the science of health: • enhance health promotion and disease prevention • improve quality of life • improve palliative and end-of-life care • enhance innovation in science and practice • develop next generation of nurse scientists
Agency for Healthcare Research and Quality (AHRQ)
Federal agency that provides evidence reports on numerous topics
Health Promotion Activities
Health promotion organizations, wellness centers, traditional healthcare centers offer different approaches - programs can be passive or active Types of programs: - Information dissemination (billboards, posters, Internet) - Health risk appraisal/wellness assessment - Lifestyle and behavior change (stress management, nutrition awareness, weight control, smoking cessation, and exercise) - Environmental control (safe air, food, and water)
Health care today (via NHS):
In the history of the NHS, there has never been such focus on improving the quality of health services. The economic downturn means an end to year-on-year financial increases, and hospitals are being challenged to respond not through indiscriminate cuts, but by driving up quality, reducing harm and improving efficiency. - Improving the quality of services is now a key requirement within the NHS, supported by initiatives such as the Commissioning for Quality and Innovation (CQIN) payment framework, and quality accounts.
Cognitivism
Recognition of developmental levels of learning and learners motivation and environment - Learning is a complex cognitive activity - Learning as the development of understandings and appreciations that help the individual function in a larger context - Learning is largely a mental, intellectual, or thinking process - Learner's perceptions are influenced by personal characteristics and experiences Social, emotional, and physical contexts affect learning
Agency for Healthcare Research and Quality (AHRQ):
The research goal is to measure those improvements in terms of client outcomes, decreased mortality, improved quality of life, and cost effective quality care - Safety and quality: risk reduction by promoting quality care - Effectiveness: improved health outcomes by using evidence to make informed health care decisions - Efficiency: translating research into practice to increase access and to decrease costs
Staff safety issues may include:
Transmission of germs to other nurses, chemical and drug exposures, postural damage related to heavy lifting and repetition; workplace violence
The nurse collaborates WITH & ABOUT:
With: clients, peers, other healthcare professionals, employer institutions, professional nursing and inter professional organizations, legislators About: clients, bioethical issues, legislation, health-related research, professional organizations
Nurse's role in health promotion
Work with people, not for them; act as a facilitator of the process Roles can include: - Consultant - Coordinator of care - Member and leader of the health profession - Provider of care - Research user - Researcher into health promotion models - Role model
Mediation
a form of alternative dispute resolution - the appointed mediator works with both sides to reach an agreement - the agreement is non-binding and either side can reject the settlement
Intrinsic approach (to improve quality)
a range of models and methods that can be put in place by individual organizations. Ideas are originally developed with the organization
Accountability:
ability and willingness to assume responsibility and consequences
Role of the Joint Commission:
accredits healthcare organizations and programs - Mission: to continuously improve healthcare for the public - Recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards
Institute for Healthcare Improvement (IHI)
an independent, non-profit organization working to accelerate improvement in healthcare systems • Focusing on facilitating collaboration among organizations through broad improvement campaigns • Provides education, seminars, and collaborative efforts to foster safety and quality
Extrinsic approach (to improve quality)
approaches include centralized government initiatives, economic drivers, and professional requirements
A manager is a role that holds:
authority & accountability
Verbal communication:
both written and spoken word, constituting only about 7% of the communicated message
Research in nursing is directed toward:
building knowledge about effects of nursing on human responses - aspects of human responses: physiological, psychological, spiritual, social , cultural, developmental, economic - implies 24 hour responsibility - research guides nurses' decisions and actions
Active health programs
client is committed to involvement diet management, self-help, exercise
Passive health programs
client is the recipient of effort clean water & air
A preventable adverse event is attributed to:
errors! (an error involves two separate definitions = commission & omission) - not all are preventable though, some are associated with the risk of treatment -- ex: prostatectomy for cancer can lead to impotence; chemotherapy can lead to anemia
Financial impact of medical errors:
estimated to be $16-18 billion per year
Active errors
occur at the level of the front line operators and their effects are felt almost immediately
National Patient Safety Foundation (NPSF):
provides resources for research, education, and campaigns to raise awareness
Decoding
responding by giving feedback
IOM reports' impact on nursing:
safe transitions across the healthcare continuum; teamwork and collaborative communications; implementation of evidence-based processes to reduce hospital acquired conditions; partnering with patients and families to lead quality of care improvements.
Non-assertive communication
submissive & aggressive-hostile
Encode
to listen to, process, and understand the information
Collective bargaining
used by groups of workers represented by a union or a negotiating body to solve workplace issues - salaries, health-care benefits, safe work environment, hiring practice
Healthcare-Associated Infections (HAIs)
• 1 in 10 patients will develop an HAI, or have a fall pressure ulcer, or medication error during his/her hospital stay • Among the leading cause of death in the US • Surgical site infection, central-line association blood stream infection, ventilator-associated pneumonia, catheter-associated UTI, and specific organisms such as C. diff and MRSA infections
Empirical nursing knowledge
•Comes from scientific evidence developed through research •Includes order and control and allows for generalization of results
Quality (definition)
"The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." -IOM A level of excellence of care based upon pre-established criteria
Health Promotion (WHO definition)
"The process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior towards a wide range of social and environmental interventions."
Receiver factors that interfere:
- Lack of attention - Prejudice and bias - Preoccupation with another problem - Physical factors such as pain, drowsiness, or impairment of the senses
Intrinsic + Extrinsic
A combination of the two approaches is needed to ensure sustained improvement - a combination is the desired situation
Bloom's domains of learning include:
Cognitive (remembering, understanding, applying, analyzing, evaluating, creating) Affective Psychomotor
Evaluate learning via:
Cognitive learning: - Observation - Written measurement - Oral questioning - Self-reports and self-monitoring Psychomotor skills: - Demonstration Affective learning: - Difficult to evaluate, but inferred through listening and observing
What to choose when planning teaching:
Content should be: accurate, current, based on learning objectives; adjusted for learners age, culture, language, and ability; consistent; selected with consideration how how much time/resources are available
Behaviorism learning theory
Identification of what is to be taught and the immediate identification of and heard for correct response Skinner's operant conditioning theory: - Classical conditioning --Association with new stimulus; Pavlov's dogs) - Operant conditioning --Frequency of a response can be increased or decreased depending on the extent it is reinforced --Reinforcement is the consequence of an action --Extinction is the process in which a conditioned behavior is "unlearned"
What is malpractice?
Malpractice is improper professional action (commission) or the failure to exercise proper professional skills (omission) that result in: injury, unnecessary suffering, or death to the client - Malpractice is one form of negligence - May occur through omission to act as well as commission of an unwise or negligent act - Malpractice means bad, wrong, or injudicious treatment of a patient professionally - It results in injury, unnecessary suffering or death to the patient
Quality Control
Requires ongoing, systematic measurement to monitor accuracy and compliance • Checking and recording refrigerator temperature for medication requiring a controlled temperature • Glucometer quality checks using a low and high control to ensure accurate readings
Case management protocols (as intrinsic approach)
• Also known as clinical pathways • Streamline charting process • Encourage documentation across multidisciplinary teams • Systematically monitor variances from prescribed plans of care • Identify how client care and progress vary from a predetermined plan • Enable more accurate assessment of client-care costs • Maintain quality-control measures
Sentinel events that require RCA:
• An unanticipated death of a full term infant • An infant abduction or discharge to the wrong family • Rape • Suicide • Hemolytic transfusion reaction • Wrong site or wrong patient surgery • Foreign object left inside patient • Severe neonatal hyperbilirubinemia • Too much radiation or radiation to wrong area
Examples of adverse events:
• Brain damage to newborn because of lack of fetal monitoring or improper use of forceps • Lack of oxygen during surgery causing brain damage. May be incorrectly intubated or wrong gasses - cross of nitrogen and oxygen lines • ER - loss of limb, brain damage or death because patient wasn't diagnosed and treated in a timely manner. If patient had been seen, would not have problems • OR - improper positioning, nerve damage or ischemia to body part • Excessive amounts of anticoagulants and patient bleeds to death during surgical procedure
Paraverbal communication:
makes up 35% of communication and includes vocal cues (tone, pauses), volume, and speed of speech, hesitations, and emotions expressed - sounds that accompany verbal language and add to the message
Nonverbal communication:
makes up 58% of communication and includes body language, facial expressions, gestures, physical appearance, touch, and spatial territory (personal space)
Bargaining
a special type of negotiation that is used when money-related issues are being discussed
Negotiation
the process of give and take between individuals or groups with the goal of reaching an agreement acceptable to both sides
Ways to access empirical knowledge
•Learn about research methods •Use systematic review conducted by expert groups
ANA's operational definition of collaboration
"A collegial working relationship with another healthcare provider in the provision of (to supply) patient care"
Sentinel Event
"A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof." - JC - Such events are called "sentinel" because they signal the need for immediate investigation and response
Health protection (primary prevention)
- Avoidance behavior - Avoiding specific problems - Thwart occurrence of insult to health and well-being
What are the beliefs basic to collaborative health care?
- Clients have a right to self-determination - Clients and healthcare professionals interact in a reciprocal relationship - Equality among all is essential in healthcare relationships - Client is responsible for his or her own health - Each individual's concept of health is important and legitimate for himself or herself - Clients have the right to accept or refuse all or any aspect of treatment - Collaboration involves negotiation and consensus, rather than questioning and ordering
Risk management goals:
- Control cost of financial - Minimize occurrences of legal claims against the organization (protect against malpractice) - Reduce injury to the lowest possible level (promote patient safety) - Protect the public - Protect healthcare personnel - maintain safe environment & equipment, training, examine systems & processes - Enhance quality of care provided (improve outcome) - Maintain client satisfaction
Develop a culture of patient safety:
- Develop reporting system that is a blame-free with open communication, analyzing the processes or system instead of pointing fingers at the individual by using quality improvement tools and finding root causes - Report all errors, near-misses, and substandard care - Disclose protocols & mistakes; acknowledge responsibility and apologize for the mistakes to the patients and families.
Doctoral Programs
- Developed out of recognition that the nursing profession needed its own research and theoretical base Ph.D. - Doctor of Philosophy—"gold standard", research-generating new knowledge Ed.D. - Doctorate in Education—teaching/educational degree DNP - Doctor of Nursing Practice—clinical/professional degree, practice focus application of research
System strategies for risk management:
- Documentation - Use of standardized forms - Knowledge, skills, and attitudes of staff - Competency and accountability of staff - Risk management activities - Quality improvement activities
Secondary prevention
- Early identification - Prompt intervention - Aims to reduce the impact of disease/injury that has already occurred; done by detecting and treating disease/injury asap to halt or slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems Examples: - regular exams and screening tests to detect disease in its earliest stages (e.g. mammograms to detect breast cancer) - daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes - suitably modified work so injured or ill workers can return safely to their jobs.
Categories of negligence than result in malpractice:
- Failure to follow standards of care - Failure to use equipment in a responsible manner - Failure to communicate - Failure to document - Failure to assess and monitor - Failure to act as a client advocate
Performance Improvement (PI)
- Focuses on processes & system - Minimizes individual blame or retribution - Investigates factors contributing to unanticipated adverse events - Internally reporting on risk reduction initiatives & effectiveness - Initiates error action reduction strategies - Recognize and acknowledge risks
Baccalaureate RN (BSN)
- Four years in length - In universities and colleges - Earn BSN or BS (nursing) - Professional orientation - Stresses independence of practice; assessment skills; leadership and management abilities BSN students are prepared in liberal education, develop intellectual skills (critical thinking), have extensive management education, learn teaching skills and principles, use and conduct research, use nursing theory and models
Primary prevention
- Health promotion - Protection against specific health problems - Aims to prevent disease or injury before it ever occurs; done by preventing exposures to hazards that cause disease or injury, altering unhealthy or unsafe behaviors that can lead to injury/disease, and increasing resistance to injury/disease should exposure occur Examples: - legislation and enforcement to ban or control the use of hazardous products (e.g. asbestos) or to mandate safe and healthy practices (e.g. use of seatbelts and bike helmets) - education about healthy and safe habits (e.g. eating well, exercising regularly, not smoking) - immunization against infectious diseases.
Sigma Theta Tau International (STTI)
- Honor society for nursing - Mission supports the learning, knowledge, and professional development of nurses to make a difference in health worldwide - Offers a variety of research grants
Joint Commission 2018 Safety Goals
- Identify patient correctly - Improve staff communication - Use machines safely - Use alarms safely - Prevent infection - Identify patient safety risks - Prevent mistakes in surgery
Risk management purpose:
- Identify, analyze, and treat potential hazards before anyone is harmed or disabled - Develop and evaluate policies and procedures that provide guidelines for the institution and direct practice - Make and carry out decisions that will limit unintended adverse events for staff and clients and minimize financial loss to the organization
Continuous Quality Improvement (CQI)
- Identify, report, analyze, correct errors, note trends, track effectiveness of changes - Ensures organizations are looking for new ways to improve existing processes
Most common factors in medication errors & their corrections:
- Illegible handwriting (corrected by using computer order entry) - Misinterpreted abbreviations (corrected by having a 'do not use' list) - Absence or presence of leading and trailing zeros (0.1 or 1.0) (corrected by creating a guideline for use) - Incomplete medication orders (corrected by creating guideline for what must be included on Rx, avoiding phone orders) - Using wrong drug name or dosage (corrected by having a look alike, sound-alike list; removal of certain meds from the unit; and safety indicators for pediatric patients) - Incorrect dosage calculations (correcting these by limiting calculation that are done at the time of administration, ready dose packaging) - Unavailable drug information (such as lack of up-to-date warnings) - Atypical or unusual and critical dosage frequency considerations - Incomplete patient information (other meds taken, previous diagnosis, and lab results) - Patient history of allergy to same medication class (corrected by allergy bands, confirmation of allergies at every stop) - Decline in renal or hepatic fxn requiring alteration of drug therapy - Lack of appropriate labeling as a drug is prepared and repackaged into smaller units
Centers for Medicare and Medicaid Services (CMS)
- Issued ruling to deny reimbursement of federal funds to pay for services by physicians and hospitals for treatment of never events • Hospitals cannot pass on costs to patients for additional care required to address never event • Private insurers implemented similar policies shortly after • Sends a message to healthcare organizations and public commitment to improve quality, cut unnecessary costs, and prevent suffering
Practical Nurses
- Licensed Practical Nurses (LPNs) - Licensed Vocational Nurses (LVNs) - Most programs are 12 to 18 months long - National council Licensure Examination for Practical Nurses (NCLEX-PN) Scope and Function - Nurse practice acts vary from state to state - Responsible for stable patients - Patients with common health conditions
Transcultural client teaching guidelines:
- Obtain teaching materials in languages used by client - Use visual aids such as pictures, charts - Use concrete rather than abstract words - Allow time for questions - Avoid use of medical terminology - Validate in writing if pronunciation is a problem - Use humor cautiously - Avoid slang - Don't assume that a nod means comprehension - Invite and encourage questions - Consider same-sex teacher if content is related to personal areas of the body - Include the family - Evaluate whether learning objectives have been met
Barriers to communication:
- Probing - Testing - Rejecting - Changing topics and subjects - Unwarranted reassurance - Passing judgment - Giving common advice - Failure to listen - Improperly decoding client's intended message - Placing nurse's needs above client's needs - Stereotyping - Agreeing and disagreeing - Being defensive - Challenging
How we improve quality:
- Quality assurance (QA) - Continuous quality improvement (CQI) - Total quality management (TQM) - Benchmarking - Leapfrog group - Quality indicators (QIs) - National Patient Safety Foundation (NPSF) - Institute for Healthcare Improvement (IHI)
Nursing delivery models: Total Patient Care
- case method - earliest model of nursing care - private-duty nurses - client-centered - client has consistent contact with one nurse during shift
Quality & Safety Education for Nurses (QSEN) competencies:
- client centered care - teamwork and collaboration - EBP - safety - informatics
Tertiary prevention
- Restoration and rehabilitation - Aims to soften the impact of an ongoing illness or injury that has lasting effects; done by helping people manage long-term, often complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life and their life expectancy Examples: - cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.) - support groups that allow members to share strategies for living well - vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.
4 interventions to reduce Med Errors
- Rights of medication administration - Medication reconciliation - Pharmacist participation - Medication standardization
Improving quality is about making healthcare:
- Safe: avoid injuries to patients during care - Effective: provide care that is evidence-based to those who can benefit (avoid over and underuse) - Patient centered: respectful and responsive to patient preferences, needs, and values - Timely: reducing waits and delays - Efficient: avoid wasting equipment, supplies, and energy - Equitable: care doesn't vary in quality based on personal characteristics
Implementing a teaching plan:
- Schedule best time for learner - Include family or caregivers as appropriate - Pace the session appropriately - Control the environment and avoid distractions - Use teaching aids - Assist learners in discovering content for themselves
Organizing learning experiences:
- Start with something the learner is concerned about - Begin with what the learner knows - Address first any area that is causing anxiety - Teach basics first - Schedule time for review of content and questions
Root Cause Analysis (RCA)
- The JC requires use of root cause analysis (RCA) to investigate the processes and systems that contribute to a sentinel event - RCA is a tool that helps identify and clarify the bottom line factors that precipitate an error or near miss - RCA focuses on systems and processes, not on individual performance - The RCA process repeatedly digs deeper into an issue by asking "why" questions until no additional logical answers can be identified - A team of people representing the areas that are involved in an event is brought together to do this analysis. This team begins with a standardized template called an Ishikawa diagram (AKA fish bone diagram, or cause & effect diagram)
Adverse events/incidents that must be reported in Florida (Code 15):
- The death of a patient - Brain or spinal damage or a patient - The performance of a surgical procedure on the wrong patient - The performance of a wrong-site surgical procedure - The performance of a wrong surgical procedure - The performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patients diagnosis or medical condition - The surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage is not a recognizes specific risk, as disclosed to the patient and documented through the informed-consent process - The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure
Risk Management definition:
- The identification, investigation, analysis and evaluation of risks and the selection of the most advantageous method of correcting, reducing or eliminating identifiable risks - Risk management includes both administrative and clinical activities which control unintended adverse events for staff and clients and minimize financial loss
Accreditation
- The process by which an organization is appraised and granted accreditation based on predetermined standards and measurement criteria. - Accreditation is voluntary, although there are incentives. -- Many governmental and non-governmental organizations will provide education/research grants and reimbursement of fees for care only to accredited organizations.
Challenges & opportunities of EBP
- There is a gap between research and practice - Implementing practice changes - Providing high-quality care with accountability - Confidence in decisions based on scientific evidence
Sender factors that interfere:
- Unclear speech - Monotone voice - Poor sentence structure - Inappropriate use of terminology or jargon - Lack of knowledge about the topic
Objectives of collaborative practice models:
- Use a multidisciplinary, integrated, participative framework - Enhance continuity across a continuum of care - Improve client and family satisfaction - Provide quality, cost-effective, evidence-based care that is outcome driven - Mutual respect, communication, and understanding - Synergy among clients and providers - Opportunities to solve system-related issues and problems - Develop interdependent relationships and understanding
Masters Degree (MSN or MS)
- Variety of master's degree programs - Continue to be a great demand for Master's level nurses, especially in medically underserved areas - Clinical and non-clinical tracks --Many clinical programs are moving to DNP as outcome --Non-clinical include Nurse Leader, Nurse Executive, Nurse Educator
Nursing delivery models: Primary Nursing
- a system in which one nurse is responsible for total care of a number of clients 24/7 - provides comprehensive, individualized, and consistent care - associates provide care, but the primary nurse plans and coordinates care
Caring leadership
- an extension of transformational leadership - good management is a matter of love - proper management involves caring for people, not manipulation
Servant leadership
- based on the desire to serve first; then conscious choice brings one to aspire to lead - leader and followers work together to attain desired goal; decision making is shared
Transformational leadership
- emphasizes the importance of interpersonal relationships - leader serves as a role model who encourages and empowers team members to achieve team and 1personal goals - vital in creation of healthcare system the embodies community well-being, basic care for all, cost-effectiveness, and holistic nursing care
Nursing delivery models: Functional Method
- evolved from concepts of scientific management - focuses on jobs to be completed - task-oriented approach - disadvantage is fragmentation of care Ex: ER setting
Nursing delivery models: Team Nursing
- individualized nursing care given to clients by a nursing team led by a professional nurse - members include RNs, LPNs, nursing assistants - responsible for coordinated nursing during a shift - emphasizes humanistic values and individualized client care at a personal level - nurse leader motivates employees
Situational leadership
- levels of direction and support vary depending on the maturity of the group - value placed on accomplishment of tasks and on interpersonal relationship - leadership style changes based on task, urgency, and individual needs
Authoritarian leadership
- makes the decisions for the group - directive, autocratic, or bureaucratic - negative connotation
High risk management areas include:
- medication errors - complications form tests and treatments - falls - refusal of treatment or refusal to sign treatment
Laissez-faire leadership
- nondirectional leadership - minimal participation - group's members act independently of each other
Democratic leadership
- participate leadership - leader: acts as a catalyst or facilitator, seeks participation or consultation of subordinates; actively guides the group toward achieving the group goals; provides constructive criticism, offers information, makes suggestions, asks questions
Common types of errors:
- system-based - medication - surgical - healthcare-associated infections (HAIs) - diagnostic
Nursing delivery models: Interdisciplinary Team Model
- team consists of all disciplines required to provide quality care to client - each team member brings expertise to help client achieve quality outcome - all members focus on client's needs and collaborate to meet those needs
Arbitration
- usually the last step before the dispute is taken to court for litigation - can either be non-binding or binding - both parties must agree ahead of time to comply with whatever decision is reached by the arbitrator
Joint Commission goal to prevent medical errors:
1. Establish a national focus on safety • IOM report did this and raised the attention of stakeholders • Involves agencies, hospitals, healthcare workers, and patients 2. Identify and learn from errors-mandatory reporting system • Florida has a system for reporting adverse events to ACHA for over 10 years • The Joint Commission now requires reporting of certain sentinel events (preventable deaths, wrong surgery or wrong patient) 3. Raise performance standards and expectations • Clinical practice guidelines (evidence-based) • Credentialing • Policies and procedures • In-service for new policies and procedures • Clinical pathways • State Nurse Practice Acts • ANA Standards of Practice • Culture of Safety 4. Implement safety systems, "a culture of safety" in health care organizations
How many CEUs do you need in the state of FL?
24 CEUs every 24 months
Prevalence of medical errors:
440,000 deaths a year are caused by medical errors 1 out of every 25 hospitalized patients will experience an error Annually, 44-98k preventable deaths were attributed to medical errors
Which of the following scenarios is a Sentinel Event? Determine why/why not next to each choice. A. An unanticipated death of a full-term newborn. B. Lack of oxygen during surgery resulting in brain damage. C. Improper use of forceps resulting in newborn brain damage or injury. D. Death or loss of limb in the ER resulting from bad time management.
A A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Sentinel events requires an immediate investigation by the Joint Commission. The state of Florida, requires a Root Cause Analysis to be completed. All of the other answer choices are Adverse Events which are defined as "an injury caused by medical management rather than the underlying disease or condition."
Florida law requires reporting of adverse events to AHCA within 15 days (CODE 15). From the following events, which is an adverse event that must be reported? A. Patient has to go into surgery to remove a sponge that was left inside the abdomen during his last surgery B. A patient received 10 units of regular insulin instead of 5 units as prescribed C. An 80 year-old female fell in the bathroom and broke a hip and has to go into surgery for a hip replacement D. Patient contracted catheter-associated UTI while staying at the hospital
A Code 15—State of Florida, requires the following adverse event to be reported within a 15 day period - The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure.
Device User Facilities
A "device user facility" is a hospital, ambulatory surgical facility, nursing home, outpatient diagnostic facility, or outpatient treatment facility, which is not a physician's office. - User facilities must report a suspected medical device-related death or injury to both the FDA and the manufacturer.
AHRQ Patient Safety Indicators (PSI)
A set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth
Total Quality Management (TQM)
AKA continuous quality improvement, is based on the belief that the organization with the higher-quality service will capture a greater share of the market than competitors with lower-quality services - emphasis is placed on not only meeting but exceeding the expectations of the consumer
Factors to consider when assessing learning needs:
Age and developmental level Health beliefs and practices Cultural and spiritual factors Economic factors Learning styles Readiness to learn Motivation Reading level (all of these factors affect health literacy; be cautious not to stereotype or make assumptions when teaching)
Adverse Effect
An event over which healthcare personnel could exercise control and which is associated in whole or in part with medical intervention rather than the condition for which such intervention occurred, and which... • Results in one of the following injuries: -- Death -- Brain or spinal damage -- Permanent disfigurement -- Fracture or dislocation of bones or joints -- A resulting limitation of neurological, physical, or sensory function which continues after discharge from the facility -- Any condition that required specialized medical attention or surgical intervention resulting form nonemergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent -- Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patients condition prior to the adverse incident • Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patients diagnosis or medical condition • Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process • Was a procedure to remove unplanned foreign objects remaining from a surgical procedure
Blame-free culture
An unwillingness to take risks or to accept responsibility for mistakes due to a fear of criticism or prosecution - by removing the fear of stress related to punishment, nurses are able to work freely to provide the best quality care that they can
After the administration of a blood transfusion, the patient unexpectedly is experiencing signs and symptoms of a hemolytic transfusion reaction. This is an example of what type of event: Why? How do you know? A. Adverse B. Sentinel C. Malpractice D. Commission
B A sentinel event is an unexpected occurrence involving death or serious physical or psychosocial injury or the risk thereof. Adverse event is an unintended physical injury resulting or contributed by medical care that required additional monitoring. Malpractice is an improper professional action or failure to exercise proper professional skills in injury, unnecessary suffering or death of the client. Commission is when a medical professional does something that should not have been done.
When you go under review and approval by an agency for an educational degree or certification program in nursing you are receiving: A. Education B. Accreditation C. Licensure D. Certification
B Accreditation is having your education or certification approved by a third party agency or body to assure quality and standards of care are properly met. Licensure and certification are individual achievements. Accreditation is an institutional or program achievement vouching for the programs achievement of industry standards (i.e., CCNE or NLN)
Which of the following is not considered an example of Man (human) error? Define the terms and think how they influence care. A. Competency B. Broken equipment C. Fatigue D. Bias
B Broken equipment would be considered a machine/device error, not a human error. Bias, competency, and fatigue are all considered man (human) medical errors.
A patient who had been admitted into the hospital had orders to be repositioned every two hours. The experienced nurse of 15 years, went into the room to administer medications around 0900 and the patient complained of feeling discomfort in his lower back but the nurse ignored the complaint. Nine hours went by without turning the patient and it was later discovered at the end of her shift that he had a stage 3 pressure ulcer. It continued to progress and became infected. Which of the following describes this example? A. Negligence B. Malpractice C. Abandonment D. Veracity
B Malpractice is defined as an "act of negligence by a professional person as compared to the actions of another professional person in similar circumstances". Hospital policy as well as the orders said to turn to the patient every two hours. Not only did she not follow the orders but when the patient complained of discomfort and pain, the nurse completely ignored it resulting in harm to the patient. When another nurse with similar circumstances and background was called to testify, she disagreed with the RN's actions and said that she would not have made those mistakes. The first mistake was not following the orders and the second mistake was not assessing the patient when he felt discomfort and documenting this action. Negligence is under malpractice, but because this person is a professional and had certain standards to uphold, it would not just be considered negligence. Abandonment is not correct in this situation because the nurse was there her whole shift and did follow other duties, such as medication administration during her shift. Veracity is about truthfulness and does not apply to this situation at all.
Which of these are the highest levels of education for nursing and are correctly matched with their focus? A. Ed.D. with a focus on research, DNP with focus on practice B. Ph.D with a focus on research, DNP with a focus on practice C. Ph.D with a focus on research, Ed.D with a focus on practice D. Ph.D with a focus on practice, DNP with a focus on research
B Ph.D is a Doctor of Philosophy and this is considered the "gold standard", research generating. DNP is Doctor of Nursing Practice and it is a more of a focus on practice. Ed.D is a Doctorate in Education and it is a teaching/educational degree.
Which is true regarding sentinel events? How do sentinel events differ from Adverse Events? A. All sentinel events occur because of an error B. Every error results in a sentinel event C. Wrong site surgery is a sentinel event D. A sentinel event is an injury caused by medical management rather than the underlying disease or condition of the patient
C A. is false because not every sentinel event occurs because of an error (such as the events of rape or suicide) B. is false because not all errors result in sentinel events, such as those which don't result in death or injury C. is true because a wrong site surgery is defined as a sentinel event D. is false because the definition provided is for an adverse effect
Which Doctoral level degree is considered the "gold standard", and is awarded for research-generating new knowledge? A. BSN B. DNP C. Ph.D. D. Ed.D.
C BSN is a Baccalaureate in Science of Nursing and it is not a doctoral level degree, DNP is a Doctor of Nursing Practice—clinical/professional degree, practice focus application of research and Ed.D. is a Doctorate in Education—teaching/educational degree.
Which is NOT a benefit of receiving a Bachelor of Science in Nursing? On each response, ask "Is this true?" A. BSN students have community health education. B. BSN students use and conduct research. C. BSN programs are traditionally a technical orientation to bedside care. D. BSN students develop intellectual skills like critical thinking, writing, and public speaking.
C BSN programs are not traditionally a technical orientation to bedside care. This answer describes the RN-Associate Degree. Yes, BSN graduates are all educated to be competent clinicians at the bedside, but the education does not exclusively focus on technical competencies. A is correct because BSN nursing students complete a community health rotation clinical. B is correct because BSN students are encouraged and required to use research in coursework. D is correct because BSN students are required to know how to make decisions in critical situations, write proper research and report, and know how to speak in public for research presentations and in rounds in the hospital setting.
The following are similarities in BSN and ADN students except: A. have national standards to meet B. seek accreditation from national source C. develops critical thinking, decision making, and leadership skills D. educational programs are flexible
C Diploma, ADN, and BSN need to graduate from an accredited program in order to take the NCLEX-RN. In order for the program to be accredited the institution has to meet set standards established by the government or nongovernment agency. BSN students develop intellectual skills like critical thinking to prepare the nurse for public health nursing, teaching, administration, and supervisory positions in hospitals.
The following are all common causes of malpractice and negligence in nursing include all but which one? Consider how communication and/or collaboration and collegiality are related to potential for error. A. Failure to document B. Failure to challenge clinician order that is incorrect C. Failure to give PRN pain medication at 8am D. Failure to communicate findings to the doctor
C The most common malpractice and negligence of nursing care is failure to communicate (D: failure to communicate findings to doctor), Failure to document (A) and Failure to act as a patient advocate (B; failure to challenge clinicians order that is incorrect), therefore failure to give PRN medication at 8am is not negligence or malpractice, as it is given on an as needed basis and not always at 8am.
Which is NOT considered a sentinel event? What is a sentinel event? A. Hip surgery was performed on the wrong patient B. A sponge was left inside of patient's abdomen during a C-section C. A nurse administered Hydroxyzine instead of Hydralazine without any adverse effects D. A cancer patient was given radiation to the wrong area
C This is correct because a sentinel event is defined as "an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof." Answer choices A, B, and D all led to serious injury. While C is an error, it did not result in injury or death.
Commission
Causes harm, wrong plan to achieve an aim • Error in performance of an operation, procedure, or test • Error in administering the treatment • Error in the dose or method of using a drug • Avoidable delay in treatment or responding to abnormal test • Inappropriate (not indicated) care -- Examples: lookalike and sound alike medications; failure to identify surgical sites; failure to identify patients using two patient identifiers; restraint injuries
Factors that affect communication:
Change--Fear of the unknown Anger --Positive or negative expression Group dynamics--Unwritten rules Competition --Peer evaluation Working environment--Coping with difficult behavior Stress --A destructive circle
Two or more students from different professions learning from or with each other to enable effective collaboration and improve health outcomes is called A. Interdisciplinary B. Transprofessional C. Interprofessional D. All of the above
D Interprofessional education is also called transprofessional and interdisciplinary education
What type of medical error poses the greatest threat? Why? A. An active error B. Man error C. Machine error D. Latent error
D Latent errors pose greatest threat to safety in complex systems because they are often unrecognized and have the capacity to result in multiple types of active errors. Latent errors are removed from the direct control of the operator and include things such as poor design, incorrect installations, facility maintenance, bad management decisions, and poorly structured organizations. A: Active error- Active errors occur at the level of the front line operators and there effects are felt almost immediately B/C: Man and machine errors are more readily noted than system/method errors. Machines/devices: rechecking is KEY to prevention
The nurse enters the room of a patient who seems to be very angry with the health care system. As the nurse is taking the patient's blood pressure, the nurse has to remind the patient what blood pressure is because she forgot. Embarrassed and angry, the patient then gets very defensive and asks the nurse "Are you even holding the stethoscope in the right spot, you look like you've never done this before." Understanding that the patient has a very disapproving attitude, what is the nurse's best response? Consider effective communication and what response would diffuse the situation and what may potentially escalate the frustration. A. Call the physician to order restraints B. Leave the room to give the patient some space as she cools down C. Ask the patient why she would say something so offensive D. Apologize to the patient for making her feel uncomfortable with her service
D This is the correct answer because the nurse has encountered a problem patient or a suit-prone patient. The best way to deal with these patients is to be understanding, apologetic, etc. Leaving the room may give the impression that the nurse is ignoring the patient's comments (postponing addressing the conflict); whereas, asking why she would ask something so offensive potentially escalates the patient's frustration. (See communication slide for barriers.) The restraints response is not reasonable.
Omission
Failure to complete a planned action as intended • Failure to provide prophylactic treatment • Failure to communicate important information in a timely manner • Unavailable patient information • Unavailable drug information (not up-to-date) • Limited staff education • Limited patient education • Substandard care: hospital acquired infections (HAI) Examples: - Failure to gather and chart client information adequately - Failing to recognize the significance of certain information (lab values, vitals) - Interpret and carry out a doctor's orders - Perform nursing tasks correctly - burning patient, medication erros - Patient at high risk for disease and did not give meds (ex: baby aspirin with family hx of MI) - Adequate monitoring of follow-up treatment
Humanism
Focus on feelings and attitudes Importance of identifying learning needs, responsibility, and self-motivation - Focuses on cognitive and affective areas of the learner - Holistic philosophy of care - Prominent members: Abraham Maslow, Carl Rogers - Learning is believed to be self-motivated, self-initiated, and self-evaluated - Learning focuses on self-development and achieving full potential
Psychomotor Domain
Learning related to actions and motor skills--physical functions, reflex actions and interpretive movements. Traditionally, these types of objectives are concerned with the physically encoding of information, with movement and/or with activities, and the gross and fine muscles used for expressing or interpreting information or concepts
Affective Domain
Learning related to attitudes, feelings, & emotions
Document the teaching:
Make sure you include: diagnosed learning needs, learning objectives, topics taught, client learning outcome achieved, need for additional teaching, and resources provided
How & Why Errors Happen:
Man (Human)/People - fallible and imperfect - bias, competency, complacency, distractions, fatigue, increased workloads, new info, rushing, staffing Machines/Devices - faulty medical devices Methods/Systems - highly technical, poorly integrated, lack of consistency, rapidly changing *man & machine are more readily noted than system/method errors
Factors that facilitate learning:
Motivation (incentive to learn, readiness) Active involvement Feedback Simple to complex Repetition Timing Environment
What is negligence?
Negligence is the omission or failure to do something a reasonable or prudent person would do • Example of omission: car maintenance—you don't take care of the breaks, tires etc and then you are involved in an accident because of the car Negligence may also be doing something a reasonable person would not do • Example: leaving an infant in a hot car for three hours; or leaving children alone at home and they are killed in a house fire Negligence may be intentional or unintentional Negligence includes use of unsafe products and failure to maintain a safe environment
Behavior Change Model
Precontemplation - Negative aspects of the change outweigh the benefits Contemplation - Seriously considers changing a specific behavior Preparation or planning - Advantages of changing the behavior outweigh the disadvantages and person makes specific plans to accomplish the change Action - Actively implements the behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones Maintenance - Integrates newly adopted behavior patterns into his or her lifestyle Termination - Person has no desire to return to previous unhealthy behavior and believes he or she will not relapse
Why does quality improvement matter?
Quality care leads to improved outcomes. Improved outcomes are associated with reimbursement. Reimbursement is key to funding of facilities. More funding = quality care, and around the circle it goes
Cognitive Domain
Remembering - Recognizing or recalling knowledge from memory. Remembering is when memory is used to produce or retrieve definitions, facts, or lists, or to recite previously learned information. Understanding - Constructing meaning from different types of functions be they written or graphic messages, or activities like interpreting, exemplifying, classifying, summarizing, inferring, comparing, or explaining Applying - Carrying out or using a procedure through executing, or implementing. Applying relates to or refers to situations where learned material is used through products like models, presentations, interviews or simulations. Analyzing - Breaking materials or concepts into parts, determining how the parts relate to one another or how they interrelate, or how the parts relate to an overall structure or purpose. Mental actions included in this function are differentiating, organizing, and attributing, as well as being able to distinguish between the components or parts. When one is analyzing, he/she can illustrate this mental function by creating spreadsheets, surveys, charts, or diagrams, or graphic representations Evaluating - Making judgments based on criteria and standards through checking and critiquing. Critiques, recommendations, and reports are some of the products that can be created to demonstrate the processes of evaluation. In the newer taxonomy, evaluating comes before creating as it is often a necessary part of the precursory behavior before one creates something. Creating - Putting elements together to form a coherent or functional whole; reorganizing elements into a new pattern or structure through generating, planning, or producing. Creating requires users to put parts together in a new way, or synthesize arts into something new and different thus creating a new form or product. This process is the most difficult mental function in the new taxonomy.
Latent errors
are removed from the direct control of the operator and include things such as poor design, incorrect installation, facility maintenance, bad management decision, and poorly structured organizations - pose the greatest threat to safety because that are often unrecognized and have the capacity to result in multiple types of active errors
Negligence in healthcare is:
conduct which falls below the standard of care established by law and other means for the protection of clients and staff against unreasonable risk of accident or injury examples: • Failing to gather and chart client information adequately • Failing to recognize the significance of certain information (lab values, vital signs) • Interpret and carry out a doctor's orders • Perform nursing tasks correctly - burning patient, medication error
Authority:
official power given by organization to direct work of others; conveyed through leadership action
AHRQ is a:
primary governmental agency focused on designing research to improve safety & quality off are, control costs, increases access to essential services - and is responsible for the Consumer Assessment of Health Plans (CAHPS)
Who is ultimately responsible for the RM goals?
the governing board
Research enables the nurse to:
• Describe situations about which little is known • Explain phenomena that have no been well understood • Predict probable outcomes • Control occurrence of undesired outcomes • Initiate activities to promote desired outcomes In clinical practice: - identify the problems in need of investigation - support the research process - assists with data collection and analysis
Risk Management (as intrinsic approach)
• Focuses on identifying, analyzing, evaluating risks • Reduces risk to decrease harm to clients • When an adverse event does occur, attempts are made to minimize losses • Is interdisciplinary in nature • Includes aspects of detection, education, and intervention • Nursing staff is key to any risk management program
Hospital Value-Based Purchasing (HVBP)
• Hospitals will be paid for inpatient acute care services based on the quality of care, not just quantity of the services provided • This program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS), based on the quality of care they deliver.
Surgical errors
• In 2014, the Joint Commission found retention of foreign body as most frequent occurring sentinel event • 1 out of every 2 surgeries (50%) had an adverse drug event and/or medication error
Diagnostic errors
• Inaccurate diagnosis can lead to ineffective to treatment and unnecessary procedure, inevitably putting the patient at severe risk of harm • More than 12 million outpatient are recipients of diagnostic error, and more than half of those errors were potentially harmful
Leapfrog Group
• Includes private and public purchasers of healthcare benefits • Healthcare organizations voluntarily submit data related to quality and safety and receive comparison reports to assess their performance • Information is made available to consumers to assist in making decisions about hospital care
System-based errors
• Lacking consistency in delivery of care or the process • Formal means of addressing and correcting near missed • Have an internal system for review
Major concerns for direct care in nursing:
• Monitoring patient status (surveillance) • Nursing interventions • Helping patients compensate for loss of function • Providing emotional support • Providing education • Integration & coordination of care
Medication errors
• Most frequent type of error • Adverse drug events (ADE) = 700k visit to the ER per year, with 15% ending in inpatient admitting
Quality Improvement Organization (QIO)
• The QIO is a federal program designed to review medical care, verify its necessity, and assist Medicare and Medicaid beneficiaries with complaints about quality of care • QIO goals: -- Improving quality of care for beneficiaries -- Protecting the integrity of the Medicare trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting -- Protecting beneficiaries by expeditiously addressing individual complaints, such as: beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); other related responsibilities as articulated in QIO-related law
Purpose of scientific research
•Description, Exploration, Explanation, Prediction, Control
