Nursing Final Exam

Which is the better aim statement? Reduce all types of hospital-acquired infections by as much as possible, as quickly as possible. Decrease the rate of hospital-acquired pneumonia for patients in the ICU from 23 infections per 1,000 catheter days to less than 5 infections per 1,000 catheter days by May 1.

Decrease the rate of hospital-acquired pneumonia for patients in the ICU from 23 infections per 1,000 catheter days to less than 5 infections per 1,000 catheter days by May 1.

Psychomotor Domain

Development of motor or physical skills Teaching method: Demonstration, practice, games motor skills

Regulatory and Accreditation Agencies

Drive quality improvement efforts in health care facilities Almost all regulatory and voluntary accrediting agencies require quality management in some form -Centers for Medicare & Medicaid Services (CMS) - Administers the Medicare program - Pay for performance - Requires quality management in "Conditions of Participation" -The Joint Commission (TJC)

•It is late at night during a particularly hectic shift. A distressed young female having an allergic reaction arrives in the ED. She has developed a rash and is beginning to wheeze. Dr. Andrew, who is new to the ED, orders Benadryl 125 mg IV. Clara, an experienced pharmacy technician, questions the drug dosage. •Dr. Andrew repeats his order for Benadryl 125 mg IV. Clara pursues her challenge a second time, stating, "Dr. Andrew, that dose seems high. I've never dispensed more than 50 mg IV at a time before." "Yes, you're right. I was confusing the dose with that for Solu-Medrol," states Dr. Andrew. •Dr. Andrew changes his order, she repeats the correct order back to him, and the correct dose of Benadryl is administered.

Example of Two Challenge Rule

HIPAA

HIPAA in short, is a set of rules for hospitals and health care providers to ensure that medical records, medical billing, and patient accounts meet certain consistent standards for handling, documentation, and privacy. •With the advent of electronic health data, Congress in 1996 enacted HIPAA which stands for the: •Health •Insurance •Portability and •Accountability •Act

The Joint Commission (TJC)

Health care organizations voluntarily seek TJC accreditation to demonstrate that they have achieved a "gold seal of approval" in quality and safety standards TJC is one of the first accreditation agencies to embrace QI principles as an accreditation requirement in hospitals TJC requires accredited hospitals to collect standardized measures referred to as the National Hospital Quality Measures (Core measures) Create the yearly National Patient Safety Goals An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.Our Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings.

Patient-centered care

Knowing the patient well enough to be able to see health care situations through the patient lens with recognition of patient's values and health beliefs

Provider needs to see the lab report immediately

Laboratory technician

•Safety:

Minimize risk of harm to patients and providers through system effectiveness and individual performance; apply knowledge of human factors, value learning from adverse event analysis, and support a just culture

Stopping a medication that is shown to be harmful is an example of which principle?

Nonmaleficence

Step 4: Testing Changes

Plan to improve -Questions & predictions -Who/what/where/when? -Develop a strategy Do -Carry it out on a small scale -Pilot the change -Observe the test -Document results Study -Draw run charts -Analyze the data -What did you learn? Act (Adapt, Adopt, or Discard) -Refine the change and plan for the next cycle -Or plan for implementation

The definition of this competency is: To minimize risk of harm to patients and providers through system effectiveness and individual performance. To apply knowledge of human factors, value learning from adverse event analysis, and support a just culture

Safety

Type of evidence that compiles and summarizes evidence from research studies related to a specific clinical question; employs comprehensive search strategies and rigorous appraisal.

Systematic Review

TeamSTEPPS

Team Strategies and Tools to Enhance Performance and Patient Safety based on more than 30 years of research and evidence Team training programs have been shown to improve attitudes, increase knowledge, and improve behavioral skills

The mission of this agency is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used. It bridges research and clinical practice.

The Agency for Healthcare Research and Quality (AHRQ)

This agency is a nonprofit institution that provides independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine.

The Health and Medicine Division (HMD). Previously known as the Institutes of Medicine HMD's aim is to help those in government and the private sector make informed health decisions by providing evidence upon which they can rely. Each year, more than 3,000 individuals volunteer their time, knowledge, and expertise to advance the nation's health through the work of HMD.Many of the studies that HMD undertakes are requested by federal agencies and independent organizations; others begin as specific mandates from Congress. While our expert, consensus committees are vital to our advisory role, HMD also convenes a series of forums, roundtables, and standing committees, as well as other activities, to facilitate discussion; discovery; and critical, cross-disciplinary thinking. HMD previously was the Institute of Medicine (IOM) program unit of the National Academies. On March 15, 2016, the division was renamed HMD, building on the heritage of the IOM's work in medicine while emphasizing its increased focus on a wider range of health matters. To learn more, please visit About Our Division Name.

This agency is an independent not for profit organization that accredits organizations for meeting certain performance standards. Creates the NPSG

The Joint Commission An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. Our Mission: To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. Vision Statement: All people always experience the safest, highest quality, best-value health care across all settings.

QI

Using a systematic, data guided approach to improve processes or outcomes. Uses a system to monitor and evaluate the quality and appropriateness of care based on EBP and research. Uses a systematic method for improving processes or outcomes. Projects are site specific. Plan, Do, Study, Act (PDSA); Root cause analysis What is the best way to improve wound care documentation?

Compromise

both people give up something to experience partial goal attainment refers to a bargaining process that often results in a less-than-ideal solution as concessions are made (one party may be willing to give up something on this issue to gain leverage for another). Still, this tactic may be useful in arriving at a temporary settlement on a complex issue, or a quick fix when time is of the essence. It's best used for issues of mild to moderate importance - you wouldn't want to compromise on an issue of patient safety, for example. And it may work well when both parties have equal power in the hierarchy and are equally committed to their position. Overuse of this style can have negative consequences, however. Parties may lose sight of long-term goals or become cynical as concessions are made to keep people happy without resolving the original conflict. A frequent compromiser may be seen as having no firm values.

STUDY

complete the analysis of the data; check: compare data to predictions; summarize what was learned

Psychological safety

creating an environment where people feel comfortable raising concerns and asking questions and have opportunities to do so.

Evaluation Teaching Process

determine outcomes of teaching-learning process. Measure patient's achievement of learning outcomes Reinforce information as needed

Planning Teaching Process

establish learning outcomes in behavioral terms. Outcomes must have action verbs; they describe behavior and are time-sensitive identify type of teaching method to use

Affective Domain

expression of feelings and emotions, and the development of values, attitudes, and beliefs teaching method: role play, discussion attitudes

QSEN Definition of Teamwork and Collaboration

function effectively within nursing and Inter-professional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care

Negotiation

gaining genuine agreement on matters of importance to team members, patients, and families.

Assessment Teaching Process

gather data about patients's learning needs, motivation, ability to learn, and health literacy

Accountability

holding individuals responsible for acting in a safe and respectful manner when they are given the training and support to do so.

QI is the process used to...

identify and resolve performance deficiencies. The quality improvement includes measuring performance against a set of predetermined standards. In health care, these standards are set by the facility and consider accrediting and professional standards. -The QI process focuses on the assessment of outcomes and determines ways to improve the delivery of quality care. -Joint Commission's accreditation standards require institutions to show evidence of QI in order to maintain accreditation status.

Diagnosis Teaching Process

identify patients learning needs on basis of these domains of learning identify learning need or conditions that interfere with learning

motivation to learn

influenced by a person's belief of the need to know something

CONFIDENTIALITY

is disclosure of information with the patient's consent for health care purposes or when legally required. Ex: Nurses respect the patient's right to privacy and keep patient information confidential.

Leadership

leaders who promote and facilitate teamwork, improvement, respect, and psychological safety (see below). Improvement and measurement: improving work processes and patient outcomes using improvement science, including measurement over time.

role of nurse in patient education

legally responsible to provide patient education to all patients, regardless of gender, culture, age, religion, or any other defining characteristics Patients have a right to make a informed decisions Information provided must be accurate, complete, and relevant to patient's needs, language, and literacy

Basic learning principles

motivation to learn readiness to learn (willingness) ability to learn learning environment

PLAN

objective questions and predictions (why?) plan to carry out the cycle (who, what, when, where?) plan for data collection

Force or Competition

one person achieves his/her own goals at the expense of the other person, aggressive Competing is generally a negative way to manage conflict. The goal is to "win" at all costs and the style is characterized by high assertiveness and low cooperation - for example when a person uses her rank to force an issue to resolution. Yet it might be a useful tactic in an emergency when quick, decisive action is vital, or where an unpopular course of action must be implemented. A manager who uses this tactic too often, however, will likely end up with a team of unempowered nurses who are indecisive, slow to act, and prone to withhold feedback.

Accommodation

one person puts aside his/her goals in order to satisfy the other person's desires refers to smoothing things over. The goal with this tactic is to yield - to preserve harmony and relationships at all costs (although sometimes this means ignoring the issue at hand, which can be detrimental to a long-term solution). It may be used effectively when you've realized you're in the wrong, when the issue is clearly more important to the other party than it is to you, and when you want to build goodwill and demonstrate that you're reasonable. But beware! If you use this style too often, you may be seen as weak, ineffective, or fearful of change.

Avoidance

one person uses passive behaviors and withdraws from the conflict; neither person is able to pursue goals, passive Avoiding conflict is not generally advised. Yet even this tactic can be used strategically, for example to create a delay that allows people to cool down or gather more information. Experts recommend using avoidance only when the issue is of small importance, when you know you can't prevail against a more powerful opponent, or when the potential damage of a confrontation outweighs the benefits. Nurses who avoid conflict at all costs are at odds with the profession's goal to advance the standard of care delivery - they are not leaders.

Criminal Law

public law relating to relationship between individual and government. Violations can be categorized by felony and misdemeanor.

Outcome indicators:

reflect desired client outcomes related to the standard under review (patient outcomes that improve if there is greater quantity and quality of nursing care)

Process indicators:

reflect how care is provided and are established by policies and procedures (assessment, intervention, and job satisfaction)

Structure indicators:

reflect the setting in which care is provided and the available human and resource materials (supply of nursing staff, skill level of staff, and education of staff)

Continuous learning

regularly identifying and learning from defects and successes.

PRIVACY

relates to the patient's right to dignity & respect, and for personal information to be held private. Ex: Patients have the right to have their private information protected. Providers must notify patients of privacy rules.

Interprofessional Team roles and functions

scope of practice may overlap with another profession work collaboratively to provide holistic care nurse is often the manager of care must understand roles and functions of other team members in order to make appropriate referrals

Client is having difficulty swallowing a regular diet

speech pathologist

health literacy

the cognitive and social skills that determine the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health

Health literacy tips and tricks

use plain language use health care information that is

ACT

what changes need to be made? next cycle?

Harm

•"Unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death" (IHI Global Trigger Tool)

Briefs (Time Out, Huddle)

•A team briefing is an effective strategy for sharing the plan •Usually occur before a procedure •Briefs should help: Form the team, Designate team roles and responsibilities, Establish climate and goals, Engage team in short- and long-term planning •Example: Time-Out prior to surgery

What are National Patient Safety Goals?

•Developed in response to the IOM's landmark report "To Err is Human: Building a Safer Health System" •Started in 2002 to address specific concerns about safety •National plan to prevent patient harm in clinical practice •Based on actual patient harm & deaths from reported sentinel events •Created yearly by The Joint Commission •Recommend evidence based standards of care to solve the problems •Emphasize system wide process improvement •Enforced by The Joint Commission (tied to accreditation) The emphasis that the National Patient Safety Goals place upon system-wide processes provides a constructive framework for addressing medical errors. Rather than promote a culture of "blame and shame" that punishes individuals for mistakes, the National Patient Safety Goals focus on ways that organizations can improve their processes to help individuals avoid mistakes in the first place.

Electronic Medical Record (EMR):

•Digital version of the traditional paper-based medical record for an individual office visit or hospital admission. One function.

Two Challenge Rule

•Empowers all team members to "stop the line" if they sense or discover an essential safety breach. •Team member being challenged must acknowledge that concern has been heard. •This is an action never to be taken lightly, but it requires immediate cessation of the process and resolution of the safety issue. •If the safety issue still hasn't been addressed: Take a stronger course of action

Feedback

•Feedback is information provided for the purpose of improving team performance

Barriers to Implementation of EHRS

•Financial costs •Interoperability •Psychological •Time •Privacy and Security Concerns

Goal 6: Identify patient safety risks

•Find out which patients are most likely to die by suicide •Conduct a risk assessment •Address immediate safety needs Mental Health counselors are available 24/7, no cost to patient/do not need an MD order! Consult them even if you are "not sure" - better to be safe than sorry! Be aware strangulation materials (I.V. tubings, bedding/linens, call light) - be aware of adjoining bathrooms. Use a Constant Observer "Code Exit" - call immediately! "Look up!" - Do not leave the patient! If patient makes suicidal/depressive ideations, STAY with the patient and ask someone else to consult a Mental Health Couselor.

Teamwork and collaboration:

•Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care

Goal 2: Improve staff Communication

•Get important test results to the right staff person on time •Organization must have in place written policies that cover: •definition of critical results of tests and diagnostic procedures; •by whom and to whom critical results of tests and diagnostic procedures must be reported; •acceptable lengths of time for reporting results.

Health Information Technology for Economic and Clinical Health Act (2009)

•Goal of both the Bush and Obama administrations was to have universal EHRS adoption in the United States by 2014 •25 billion dollars awarded to organizations to implement EHRS •Established "Meaningful" use guidelines for organizations to ensure standardization.

Point of Care Technologies

•HIT directly at the bedside or within close proximity to where services are delivered •Paramount to deliver safe, efficient, and quality patient care •Easy access to patient data (past and present), references, policies, procedures, evidence-based literature •Handheld computers, laptops, tablets, smartphones, and PDAs •Moves from practice that relies on memory to continuous use of resources as they are needed

Three types of human behavior

•Human error: Inadvertently doing something other than what you should have done. Ex: you suddenly recognize that you are speeding without intending to do so. •At-risk behavior: making an intentional behavioral choice that increases risk-without perceiving that heightened risk or believing that it is justified. Ex: you consciously drive 72mph because it feels safe to you, even though the posted speed limit is 65mph •Reckless behavior: consciously disregarding a visible, significant risk. Driving drunk involves choosing to put oneself and others in harm's way

Goal 5: Prevent Hospital Acquired Infections

•Improve hand hygiene •Use proven guidelines to prevent infections that are difficult to treat •Use proven guidelines to prevent infection of the blood from central lines (CLABSI) •Use proven guidelines to prevent infection after surgery (SSI) •Use proven guidelines to prevent infections of the urinary tract that are caused by catheters (CAUTI)

Principles and Tips for Social Media:

•In general, principles and tips from the ANA and NCSBN include: 1.Don't share or post information or photos of patients 2.Maintain professional boundaries with patients 3.Do not post comments about employers, co-workers even if names are omitted 4.Do not take photos or videos of patients on cell phones or devices 5.Report breaches in confidentiality or privacy

Evidence-based practice

•Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care

Transparency

•It is safe to talk about mistakes and errors. •People learn from these events and treat them as opportunities to improve.

What makes someone a leader?

•Leaders are not identified by position or rank; they exist at all levels and in all groups. •Strong leaders in health care, who promote a culture of safety, do the following: •Make yourself approachable through psychological safety and trust •Establish shared goals •Invite everyone into the conversation

Electronic Health Record System (EHRS):

•Longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Has many functions. (8 Core Functions)

Goal 7: Prevent mistakes in surgery

•Make sure the correct surgery is done on the correct patient and at the correct place on the body (Pre-op verification) •Mark the correct place on the patient's body •Pause before the surgery to make sure that a mistake is not being made.

Situation Monitoring (an individual skill)

•Process of actively scanning and assessing elements of the situation to gain information or maintain an accurate understanding of the situation in which the team functions. •Skill that can be taught, developed, and improved •Enables team members to identify potential issues or minor deviations early enough to correct and handle them before they become a problem or pose harm to the patient.

Medication Reconciliation (Make consistent)

•Record and pass along correct information about a patient's medications across continuum of care •Find out what meds the patient is taking •Compare those meds to new medications given to the patient •Make sure the patient know which meds to take when they are at home •Tell the patient it is important to bring their up to date list of meds every time they visit a doctor

Use proven guidelines to prevent infections that are difficult to treat

•Reduce infections due to multidrug-resistant organisms: methicillin-resistant staphylococcus aureus (MRSA), clostridium difficile (CDI), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram-negative bacteria. •Identify patients and flag in EHR •Report rates

Shared Mental Model (a team outcome)

•Result of each team member maintaining his or her situation awareness and sharing relevant facts with the entire team •Doing so, helps ensure that everyone is on the "same team"

formal feedback

•Retrospective and typically scheduled in advance •Has an evaluative quality Examples: Collaborative discussions, case conferences, individual performance reviews

-Pre-op Verification

•Right patient? •Right procedure? •Right site? •Verify this information with the patient involved, awake & alert, if possible. •Ensure relevant documentation •H&P, Informed Consent, Pre-op checklist

Handoffs

•Standardized strategy designed to enhance information exchange at critical time such as transitions in care. •Includes opportunity to ask and respond to questions •Maintains continuity of care despite changing caregivers •In the emergency department, one service takes over for another, such as gynecology taking over for general surgery for a patient with pelvic pain. •Within the hospital, a patient is moved from one unit to another, such as from the postoperative recovery room to the intensive care unit. •After being hospitalized, a patient is discharged home or to a long-term care facility. •In the outpatient setting, a primary care office transfers the patient to a specialty care practice or rehab facility.

Consequences of Misuse

•Students will be held personally accountable for their actions. •Can result in termination from the program •Can result in never getting a job at that facility •Can result in civil penalties ($100-$50,000 fines) •Can result in criminal penalties (1-10 years in jail) •Can result in punishment to the nursing department

Causes of Sentinel Events

•System problem rather than mistake of single individual •Three leading root causes 1.Inadequate communication 2.Incorrect assessment of a patient's condition Inadequate leadership, orientation, and training

Task Assistance

•Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. •Communicate clear and specific availability of time and skills •Use common courtesy when asking for help •Close the loop on task communication-ensure it was completed correctly Account for experience level

HIPAA: Privacy rule

•The HIPAA "Privacy Rule" was enacted in 2003 to establish standards for the protection and disclosure of patient health information, and specifically: •Defines identifiable protected health information (PHI), including patient identifiers like a person's name, birthdate, picture, medical diagnoses, address, social security number, etc. •Stipulates how this information may be used, by whom, and under what circumstances. •Nurses are legally and ethically obligated to keep all patient information confidential. •Only discuss the patient's status with members of the health care team who are caring for the patient •Only health care team members directly responsible for a client's care may access that client's record. •Client's have a right to read and obtain a copy of their medical record. •Nurses may not photocopy any part of the medical record except for authorized exchange of documents between facilities and providers •Staff must keep medical record in a secure area to prevent inappropriate access to the information. They may not use public display boards to list client name and diagnosis. •Electronic records are password protected and public may not view them. •Staff must use their own passwords to access information. •Nurse must not disclose client information to unauthorized individuals or a family members who request it in person or by telephone or email. •May use a code system •Communication about a client should only take place in a private setting when unauthorized individuals cannot overhear it. •Can use data for research and continuing education, but need permission from administration. •Always log off the computer •Never leave a medical record where others can access it (written or printed). •Shred any printed or written client information for reporting after client care. •Nursing students are NOT allowed to share patient information with each other, except for clinical conferences. •Do not post information about your school, clinical sites, clinical experiences, clients, and other health care staff on social media sites.

Goal 1: Identify Patients Correctly

•Use at least 2 patient identifiers •Make sure the correct patient gets the correct blood •Name and date of birth whenever... •Administering medications •Administering blood products •Taking blood samples/specimens •Providing any treatments or procedures •Delivering dietary trays

Quality improvement:

•Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continually improve the quality and safety of health care systems

Informatics

•Use information and technology to communicate, manage knowledge, mitigate error, and support decision making

Health Information Technology (HIT):

•Use of various forms of technology to improve the quality of health services to individuals and communities

Take extra care with patients on blood thinners (Heparin and Coumadin)

•Use oral unit-dose products, pre-filled syringes, or premixed infusion bags to reduce dosing errors. •Before starting a patient on Warfarin, assess the patient's baseline coagulation status, and use a current International Normal Ratio (INR) to adjust therapy •Use programmable pumps when administering continuous, intravenous heparin infusions. •Educate patients and families

Electronic Health Record Systems (EHRS) Core Functions

1. Health information and data: Use data to make diagnosis and treatment plan. Includes PMH, allergies, meds. 2. Results management: Electronic reports of lab results and radiology procedures with automated display of previous results. Shows trends. 3. Computerized provider order entry (CPOE): Allows HCP to enter standardized, legible, and complete orders. 4. Clinical decision support system: Enhances clinical performance by providing reminders, drug alerts for dosing, and clinical decision making. 5. Electronic communication and connectivity: Electronic communication between the health care team members and connectivity to the patient record across multiple care settings. Secure messaging for texting between health care workers. 6. Patient support: Connecting with the patient. Computer based patient education and home monitoring. Ex: My Chart, Apps, Telehealth 7. Administrative processes: Scheduling systems, billing, inventory 8. Reporting and population health management: Meeting public and private sector reporting requirements at the Federal, state, and local levels; address quality improvement initiatives.

What three criteria need to be met to call the situation an ethical dilemma?

1. Review of scientific data is not enough to solve it. 2. It involves a conflict between two ethical principles. 3. The answer will have a profound effect on the situation and the client

These are the three fundamental Questions that are addressed in the Model for Improvement.

1.Set an aim: How good? By when? For whom? 2.Establish measures: to know if a change actually leads to an improvement 3.Identify Changes: how are you going to achieve your aim?

Why are Core Measure results important?

1.The first and most important reason is the patient. 2. With the public reporting of quality measures compliance and cost of care, the patients can now choose the facility they think will best meet their needs. 3. Facilities that maintain higher percentages of compliance with the core measures receive higher reimbursement from Medicare and other payers = PAY FOR PERFORMANCE

EHRS "Meaningful Use"

A defined set of capabilities and standards that EHR systems must meet to ensure that their full capacity is realized and for the hospitals to qualify for financial incentives from Medicare. 1.Improve quality, safety, and efficiency, and reduce health disparities. 2.Engage patients and their families in their health care. 3.Improve care coordination between health care team. 4.Improve population and public health. 5.Ensure adequate privacy and security protections.

SBARR Technique

A framework for team members to effectively communicate about a patient's condition to one another Communicate the following information: •Situation―What is going on with the patient? •Background―What is the clinical background or context? •Assessment―What do I think the problem is? •Recommendation―What would I recommend? •Read back orders to confirm

EBP

A life long problem solving approach to clinical practice that integrates the most relevant and best research with one's own clinical expertise, and patient preferences and values. Translates the best clinical evidence, typically from research results to make practice decisions. Evaluates the best available evidence to see if practice warrants a change. Levels of Evidence In the NICU patient population, are saline peripheral IV flushes as effective as heparin in maintaining IV line patency?

Definition of safe care with example

Avoiding injuries to patients from the care that is intended to help them. Ex: Nurse checks 2 identifiers prior to drawing blood work.

Definition of efficient care with example

Avoiding waste, including waste of equipment, supplies, ideas, and energy. Ex: Duplication of a chest x-ray

Call-Out

A strategy used to communicate important or critical information •Critical information is called out during the situation •It informs all team members simultaneously during emergency situations •It helps team members anticipate next steps •Works best to direct information to specific individual on the team so that a response can be given •Example: During code blue, the nurse checks for a pulse and calls out "no pulse" and looks at the code leader. The code leader responds with "continue compressions."

Information Technology in the Clinical Setting

Electronic health records offer nurses and other team members information when, where, and how they need it.

Conditions That Undermine Situational Awareness

Failure to— •Share information with the team •Request information from others •Direct information to specific team members •Include patient or family in communication •Utilize resources fully (e.g., status board, automation) •Maintain documentation •Know and understand where to focus attention •Know and understand the plan •Inform team members the plan has changed

self-efficacy

a person's belief about his or her ability to perform a behavior successfully

This is a written, measurable, and time‐sensitive statement of the expected results of an improvement project

an AIM

teach-back

an evience-based approach used to assess whether or not a patient understands information

Reliability

applying best evidence and promoting standard practices with the goal of failure-free operation over time.

Time Out-Immediately before procedure!

•Active Communication among ALL team members! •Right.....patient? (Must re-verify!) •Right.....side/site? •Right.....procedure? •Right.....position? •Right.....equipment? •If there are any questions or concerns, the procedure CAN NOT start until resolution is reached! •"Time - Out" must be documented.

Medication Labeling

•All medications, medication containers, and solutions must be labeled. You must immediately discard any medication or solution found unlabeled. This requirement specifically applies to medications removed from their original containers and placed into unlabeled containers that are not immediately administered to the patient in perioperative settings. This requirement applies even if only one medication is used during the procedure.

Critical Language (CUUS)

•Assigns designated words or phrases to indicate escalating concern. •Every team member needs a shared understanding of the language and knows to stop and pay attention •I'm Concerned..." •"I'm Uncomfortable..." •"I feel it's Unsafe..." •"I'm Scared"

•Mutual support involves members:

•Assisting each other •Providing and receiving feedback •Exerting assertive and advocacy behaviors when patient safety is threatened

Debriefs

•At the completion of an event •Designed to improve outcomes •Teams decompress •What went well, what did we do good? •What could have been done better? •What lesson did we learn?

Basic Tools and Strategies for Effective Communication

•Briefs and debriefs •Repeat Back or Check Back (Closed loop) •Call-Out •SBARR •Handoffs •Critical language •Two challenge rule •DESC

Use proven guidelines to prevent CAUTI's

•CAUTI Bundle includes: •Hand Washing •Avoid unnecessary urinary catheters •Insert urinary catheters using aseptic technique •Maintain urinary catheters based on recommended guidelines •Review urinary catheter necessity daily

Use proven guidelines to prevent infection of blood from central lines (CLABSI)

•Central line bundle elements: •Hand hygiene •Maximal barrier precautions •Chlorhexidine skin antisepsis •Optimal catheter site selection (avoid femoral) •Daily review of line necessity with prompt removal of unnecessary lines

Goal 3: Use Medications Safely

•Correct labeling of medications •Take extra care with patients on blood thinners •Med reconciliation

Marking the Site

•Marking must take place with patient involved, awake & aware, if possible. •Right/Left distinction •Multiple structures (fingers/toes) •Multiple levels (spinal procedures) •The proceduralist MUST do the site marking. •Mark the initials near the site - must be visible after prep/drape.

Patient Safety

•Patient safety: •"The absence of preventable harm to a patient during the process of health care" (WHO)

Determining Accountability

•Practical questions: •Did the individuals intend to cause harm? •Did they come to work drunk or impaired? •Did they do something they knew was unsafe? •Could two or three peers have made the same mistake in similar circumstances? •Do these individuals have a history of involvement in similar events?

QSEN Definition of Safety

•Safety: minimizing risk of harm to patients and providers through system effectiveness and individual performance •Applying knowledge of human factors, value learning from adverse event analysis, and support a just culture

QSEN Competencies for Nursing

•Six QSEN competencies •Patient-centered care •Quality improvement •Teamwork and collaboration •Evidence-based practice •Safety •Informatics •Continual improvement in the six competencies allows nurses to shape the quality and safety of health care systems

Features of a Culture of Safety

•Staff are comfortable expressing their concerns. •Constantly looking for risk •Problems aren't swept under the rug. People know they will not be punished or blamed for system-based errors

STEP

•Status of the patient •Team member status •Environmental conditions •Progress toward goal

Use proven guidelines to prevent infection after surgery (SSI)

•Surgical Site Infection Bundle •Effective Antibiotic Prophylaxis •Minimal Skin Trauma Related to Hair Removal •Maintenance of Normothermia •Glycemic Control

Primary Literature

Original research studies, building blocks of evidence

Average number of times patients receive recommended oral care in 24 hours (MEASURE?)

PROCESS

Act outlining the rights of individuals in the health care setting?

Patient Self Determination Act

Definition of the competency: quality improvement

Use of data to monitor outcomes of care processes and use improvement methods to design and test changes to continuously improve quality and safety of healthcare

What is Quality Improvement (QI, PI,QC)

Use of data to monitor outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of healthcare.

This is a type of communication tool that "closes the loop" between sender and receiver.

Verbal repeat back

Cognitive Domain

occurs when an individual gains information to further develop his or her intellectual abilities, mental capacities, understanding, and thinking processes. teaching method: Lecture, Q&A session understanding

QSEN

Quality and Safety Education for Nurses

Client is needing an x-ray after a fall

Radiology technologist

Linking PDSA Test Cycles

Start small Think ahead Don't wait to begin!

Goal 4: Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

Alarm fatigue, the lack of response due to excessive numbers of alarms resulting in sensory overload and desensitization, is a national problem. From 2005 through 2008, the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database received 566 reports of patient deaths related to monitoring device alarms.

Difference between a living will, durable power of attorney, and DNR

All are Advance Directives. Living will: express wishes at end of life if patient becomes incapacitated. DPOA: designated decision maker to make health care decisions if patient is unable. DNR: Physician order after consultation with patient/family.

The definition of this competency is: To use information and technology to communicate, manage knowledge, mitigate error, and support decision making

Informatics

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) A.Bypass the firewall B.Implement the automatic sign off C.Create a password with just letters D.Use a programmed speed dial key when faxing E.Impose disciplinary actions for inappropriate access F.Shred papers containing personal health information (PHI)

Answer: B, D, E, F

Research

Applies a methodology to generate new knowledge, or validate existing knowledge based on a theory Generating or validating new knowledge based on a theory. Uses scientific methods. Qualitative and Quantitative What is the relationship between metabolic control and self care behaviors in adolescents with type 1 diabetes?

Providing vaccinations for the general population is an example of which ethical principle?

Beneficence

IOM's Recommendations for Redesign

1. Apply evidence to health care delivery-EBP 2. Use information technology-EHR 3. Align payment policies with quality improvement -Pay for performance 4. Prepare the workforce-QSEN

Purposes of Patient Education

1. Maintenance and Promotion of Health and Illness Prevention 2. Restoration of Health 3. Coping with Impaired Functions

Change Concepts

1.Eliminate waste 2.Improve workflow 3.Optimize inventory 4.Enhance the producer-customer relationship 5.Change the work environment 6.Manage time 7.Manage variation 8.Design systems to prevent errors Focus on the design of products and services

2019/2020 National Patient Safety Goals

1.Identify patients correctly 2.Improve staff communication 3.Use medications safely 4.Use alarms safely 5.Prevent infection 6.Identify patient safety risks 7.Prevent mistakes in surgery

Key Points of Conflict Resolution

1.Recognize how you resolve conflict 2.Have a timely discussion 3.Choose a private location 4.Choose "I" statements, avoid blaming statements 5.Active listening (therapeutic techniques & SOLAR) 6.All people involved must view their conflict as a problem to be solved mutually. 7.Keep the focus on delivery of quality patient care.

What percent of adverse events are due to faulty transitions (handoffs)?

80% of serious adverse events can be linked to miscommunication between caregivers when patients are transferred or handed over •Common challenges: •Adverse drug events •Lost test results •Incomplete referrals

This is the scientific method used for action-oriented learning and tests a change in the real work setting.

A Plan-Do-Study-Act (PDSA) Cycle

Conflict Resolution: DESC Script

A constructive approach for managing and resolving conflict D—Describe the specific situation E—Express your concerns about the action S—Suggest other alternatives C—Consequences should be stated

Definition of advocacy and give an example

Advocacy refers to the nurses' role in supporting clients by ensuring they are properly informed, that their rights are respected, and that they are receiving the proper level of care. Ex: writing a letter to congress supporting the ACA

Learning

Acquiring new knowledge, attitudes, behaviors, and skills through an experience or external stimulus

Three Questions and a Cycle

Asks these 3 questions and then PDSA circle The PDSA cycle gives us a way to quickly test changes on a small scale, observe what happens, tweak the changes as necessary, and then test again (perhaps with a larger or broader test group, if our confidence in the idea has grown). The PDSA cycle enables rapid testing and learning. You actually conduct PDSA cycles every day. We all test out new ideas constantly. Consider these tests, for example: 1.Set an aim: How good? By when? For whom? 2.Establish measures: to know if a change actually leads to an improvement 3.Identify Changes: how are you going to achieve your aim? 4.Test changes: PDSA cycle comes in 5.Implement changes: implement it!

Nursing Process and Teaching Process

Assessment Diagnosis Planning Implementation Evaluation

Presenting all treatment options to a patient, explaining risks in terms that a patient understands, ensuring that a patient understands the risks and agrees to all procedures before going into surgery

Autonomy

How are Core Measures Reported?

The reported results represent the percentage of patients admitted with a specific diagnosis who receive the recommended care measure. Number of patients receiving expected care Total number of patients with given diagnosis

Patient and staff satisfaction scores (MEASURE?)

BALANCING

Secondary Literature

Based on primary

Check back or Repeat Back

Check back/Repeat back is a closed-loop communication strategy used to verify and validate information exchanged. •Sender concisely states information to the receiver •Receiver repeats back what he or she heard •Sender acknowledges information is correct or corrects it •Process continues until shared understanding is confirmed •Example: One member of the team calls out, "BP is falling, 80/48 down from 90/60." Another team member verifies and validates receipt of the information by saying "Got it; BP is falling and at 80/48, down from 90/60." The original sender of the information completes the loop by saying, "Correct."

Type of evidence that is a systematically developed recommendation from nationally recognized experts based on research evidence or expert panel consensus

Clinical Practice Guideline

Core Measure Outcomes

Core measures are national standards of care and treatment processes for common conditions. Utilizes the results of evidence based medicine research (Clinical Practice Guidelines) which is evidence proven to reduce complications and lead to better patient outcomes. Core measure compliance shows how often a hospital provides each recommended treatment for certain medical conditions. Expects that every patient with the given diagnosis will receive the baseline (core) evidence based care.

•"A prominent orthopedic surgeon is preparing to perform knee surgery. He is distracted, and a nurse in the room notices the surgeon's scalpel is hovering over the incorrect knee. She wants to say something but is nervous about challenging his authority."Excuse me, Doctor," she says, "but I need some clarity about which knee you are going to operate on."The entire surgical team knows to stop immediately. As soon as they do, the physician realizes his error, and moves to the correct knee. He later thanks the nurse for using critical language.

Critical Language Example (CUUS)

This is an agreed-upon set of terms that indicates to all members of a patient care team that there is a problem.

Critical Language.

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) A.Writes the patient's room number and date of birth on a paper for school. B.Prints/copies material from the patient's health record for a graded care plan C.Reviews assigned patient's record and another unassigned patient's record. D.Gives a change-of-shift report to the oncoming nurse about the patient. E.Reads the progress notes of assigned patient's record. F.Discusses patient care with the hospital volunteer.

D, E

DNR

DNR: Physician order after consultation with patient/family.

DPOA

DPOA: designated decision maker to make health care decisions if patient is unable.

Just Culture

Defined by David Marx; recognizes that competent professionals make mistakes, should not be held accountable for system failures they have no control over. However, it has zero tolerance for reckless behavior. Two benefits: •People know that certain kinds of behavior are not acceptable •People know that they won't be punished for admitting to errors that happen when they are trying to do the right thing

IOM's Recommendations for Improvement

Establish a website that focuses on leadership, research, tools, and protocols related to patient safety; now have AHRQ and NQF Identify and learn from errors by developing public mandatory reporting systems; TJC Raise performance standards for safety through oversight organizations, professional groups, and group purchasers; Insurance groups (CMS, NDNQI) Implement a culture of patient safety

Active Leadership

Everyone is encouraged to speak up about safety concerns.

Improve Hand Hygiene

Follow either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. Wet your hands with clean, running water (warm or cold) and apply soap. Rub your hands together until they lather and scrub vigorously; be sure to scrub the backs of your hands, between your fingers, and under your nails. (Don't forget your thumbs). Continue rubbing your hands for at least 20 seconds. If you need a timer, hum the "Happy Birthday" song from beginning to end twice. Rinse your hands well under running water, then dry your hands using a clean towel, or air-dry them. Use an alcohol-based hand-rub if your hands are not visibly soiled and you don't have immediate access to soap and water. Otherwise, use soap and water.

Step 1: Set an Aim

How good? For whom? By when? Bold Realistic Clear Concise Measureable Meaningful

Crossing the Quality Chasm: A New Health Care System for the 21st Century

Identified that the healthcare system does not provide consistent high quality care to all Americans should be receiving care based on the best scientific knowledge Defined a vision for improving quality of healthcare 17 year lag between discovery of best evidence and implementation into care of patients. 40% of patient not receiving recommended care (standards of care).

Teaching

Imparting knowledge through a series of directed activities

Implementation Teaching Process

Implement teaching methods actively involve patient in learning activities include family or caregiver as appropriate

To Err is Human: Building a Safer Health System

Institute of Medicine (IOM) initiated the Quality of Healthcare in America project to help produce an improvement in quality over the next 10 years. "To Err is Human" was the first in a series of reports arising from the project Projected # of deaths from medical errors exceed those from MVC, breast cancer, or AIDS Medical errors: defined as the failure of a planned action to be completed or use of the wrong plan to achieve an aim, with highest risk for errors occurring in ICU, OR, or ED. Report identified several fundamental factors contributing to the errors: The decentralized nature of the healthcare delivery "nonsystem" Failure of the licensing systems to focus on errors The impediment of the liability system to identify errors The failure of 3rd-party providers to provide financial incentive to improve safety. Most errors were felt to be system errors rather than individual problems The report resulted in congressional funding of the Agency for Healthcare Research and Quality, which created a list of "never events" to use as the basis of a mandatory reporting system Based on 2 major studies: Concluded that 98,000 patients are killed each year from medical errors -Equivalent to three jumbo jets crashing every other day; statistics widely reported by the media Confirmed that poor quality of care is a major problem

This organization focuses on healthcare improvement worldwide. It is committed to developing the next generation of improvers.

Institutes of Healthcare Improvement (IHI)

Definition of the competency: Evidence Based Practice

Integrating best current evidence with clinical expertise and patient/family preferences and values for optimal health care.

Type of evidence that is a summary of published literature without systematic appraisal of evidence quality or strength.

Literature Review

Living Will

Living will: express wishes at end of life if patient becomes incapacitated.

Step 2: Establish Measures

MEASURES: OUTCOME measures are the measures you ultimately want to move. They tell you how the system is performing, i.e., what is the ultimate result? PROCESS measures tell you if the parts or steps in the system are performing as planned to affect the outcome measure. BALANCING measures, which are often not directly related to the aim, assess whether the changes designed to improve one part of the system are introducing problems elsewhere.

National Database of Nursing Quality Indicators (NDNQI) or Nurse Sensitive Outcomes (end results)

Measures indicators that are sensitive to nursing Patient outcomes and nursing workforce characteristics that are directly related to nursing care. Two major purposes 1. Provide comparative data to all hospitals to support quality improvement activities 2. Acquire national data for better understanding of link between nurse staffing and patient outcomes

Three types of Improvement Models

Model For Improvement (MFI): -3 questions + Cycle (PDSA) Lean: -Reducing waste of time and resources Six Sigma: -Reduces variation

Rate of hospital-acquired pneumonia per 1,000 catheter days in the ICU (MEASURE?)

OUTCOME

Must Haves: (patient medications)

Obtain a complete and accurate list of medications the patient is taking at home for EVERY patient (including OTC's, patches, herbals, topicals, inhalers) on admission. Provide an updated home med list to EVERY patient & the next provider of care on discharge. (What the patient is actually doing, not what the bottle says) -herbals, show me how you take your medications, when, and which ones, inhaler, patches, etc. (being consistent-reconciliation)

Client having difficulty using an eating utensil post CVA

Occupational therapist

Fairness

People are not unfairly blamed

Psychological Safety

People treat each other with respect. •People know their concerns will be openly received and treated with respect. •Anyone can ask questions without looking stupid. •Anyone can ask for feedback without looking incompetent. •Anyone can be respectfully critical without appearing negative. •Anyone can suggest innovative ideas without being perceived as disruptive.

Client is concerned about the side effects of Coumadin

Pharmacist

Post op hip replacement needs assistance to ambulate and regain strength

Physical therapist

Step 3: Developing Changes

Process analysis tools Benchmarking Technological solutions Creative thinking Change concepts

Client has a temp of 102 and is achy

Provider

Definition of effective care with example

Providing care based on scientific evidence to all who could benefit and refraining from care that is not likely to benefit. Ex: QI project focused on increasing the percent of patients diagnosed with a MI who receive aspirin on admission (core measure)

This occurs when an individual feels comfortable expressing an opinion, mentioning problems, or correcting errors

Psychological safety.

Definition of timeliness of care with example

Reducing waits and sometimes harmful delays for both those who receive and those who give care. Ex: QI project focused on decreasing the amount of time it takes to administer first antibiotic for pneumonia.

Client with low albumin and recent weight loss

Registered Dietician

Client is SOB and needs a nebulizer treatment

Respiratory therapist

This structured communication technique is used to standardize communication between two or more people.

SBARR (Situation, Background, Assessment, Recommendation and Read Back)

Six Dimensions of Health Care Quality

Safe: Avoiding injuries to patients from the care that is intended to help them-Do no harm Timely: Reducing waits and sometimes harmful delays for patients and providers -Avoid delays Effective: Providing the appropriate level of services based on scientific knowledge -Base care on scientific evidence Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy Equitable: Providing care that does not vary in quality because of personal characteristics -Reduce health care disparities Patient-Centered: Providing care that is respectful of and responsive to individual patients - patient controls care

What is a Sentinel Event?

Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness

3 "S's" of PDSA Cycles (Principles)

Single Step - Each PDSA contains a segment or single step of the entire process. Make ONE small change and run a PDSA cycle. Short Duration - Each PDSA cycle should be as brief as possible for you to gain knowledge that it is working or not. RAPID cycles building on each other. Small Sample Size - A PDSA will likely involve only a portion of the area you are impacting. Start with a pilot. Does not require consensus of the whole unit.

These are the three principles (3 S's) used in implementing an improvement project.

Single step Short duration Small sample size (pilot)

Client is needing medical equipment in the home after discharge

Social Worker

Client requests communion prior to surgery

Spiritual Support

***Bundles (method of standardization)

Structured way of improving the processes of care and patient outcomes. A small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes Every time, every patient Examples of current bundles •Ventilator Associated Pneumonia Bundle •Central Line Bundle •Severe Sepsis Bundle •Surgical Site Infection Bundle •CAUTI Bundle IHI developed the concept of "bundles" to help health care providers more reliably deliver the best possible care for patients undergoing particular treatments with inherent risks. Standardization: •Referred to as best known methods or best practices •Care carried out in uniform, systematic method •Employees trained to perform procedures according to standards rather than learning by watching others •Avoids haphazard changes to procedures •Increases Reliability

Maintenance and Promotion of Health and Illness Prevention

The patient acquires the ability to incorporate knowledge into everyday life in a way that promotes health

Coping with Impaired functions

The patient learns to manage permanent health alterations

Restoration of Health

The patient seeks information about regaining or maintaining their level of health following illness or injury

Information and technology skills are essential for safe patient care because:

They allow participation in systems that can identify risk for harm.

Collaboration

both people actively try to find solutions that will satisfy them both Collaborating is true problem solving. The goal is to find a mutual solution when both sets of interests are too important to be compromised - for example, when an issue of patient safety is at odds with the need to use limited resources strategically. The process of collaborating involves high amounts of both assertiveness and cooperation, as parties with different perspectives attempt to merge their insights and work through the conflict. This is generally considered the most effective style of managing conflict, yet it also has pitfalls - use it for everything and you'll find yourself spending exorbitant amounts of time sorting out trivial issues.

DO

carry out the plan document problems and unexpected observations begin analysis of data

Domains of Learning

cognitive, affective, psychomotor

Transparency

openly sharing information about the safety and quality of care with staff, partners, patients, and families.

Teamwork and communication

promoting teams that develop shared understanding, anticipate needs and problems, and apply standard tools for managing communication and conflict.

Civil Law

protects the rights of people. Torts can be categorized as unintentional, quasi-intentional, or intentional

Healthcare Information System (HIS):

•The hardware and software that enable information to be stored, retrieved, communicated, and managed

Situation Awareness (an individual outcome)

•The state of knowing the current conditions affecting one's work. •Includes knowing... •Status of the patient •Team member status •Environmental conditions •Current progress toward the goal

informal feedback

•Typically in real time •Provided on an ongoing basis •Focuses on knowledge and practical skills development •Examples: Huddles, debriefs