Role of the Nurse Quiz 1 SAFETY

purposeful inaction,

"do nothing"

IOM offers a definition of safety as

"freedom from accidental injury."

NQF refers to nurses

"the principal caregivers in any healthcare system" Examples of measures related directly to nurses are pressure ulcer prevalence, ventilator-associated pneumonia, skill mix, voluntary turnover, and nursing care hours per patient day

Types of Errors

(1) Diagnostic errors- are the result of a delay in diagnosis, failure to employ indicated tests, use of outmoded tests, or failure to act on results of monitoring or testing. (2) Treatment errors- occur in the performance of an operation, procedure, or test; in the administration of a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test result. (3) Preventive errors- occur when there are failures to provide any of the following: prophylactic treatment, adequate monitoring, or follow-up treatment. (3) Preventive errors- occur when there are failures to provide any of the following: prophylactic treatment, adequate monitoring, or follow-up treatment.

The main principles for diagnosing a problem are

(1) know the facts, (2) separate the facts from interpretation, (3) be objective and descriptive, and (4) determine the scope of the problem.

SBAR

(Situation, Background, Assessment, and Recommendation)

Team STEPPS

(team strategies and tools to enhance performance and patient safety)

AHRQ safe practices

-creating a culture of safety: different way of thinking when problem arises -making sure ppl are qualified to take care of PT. #1 cause of error: transfer and clear communication reconciliation is required by law when patient is transfered.

identify errors committed

-error of commission-occurs as result of doing something - error of omission- not doing something -error of execution- Ex: inserting catheter after breaking steril field.

QSEN competencies

-patient centered care -teamwork & collaboration - evidence based practice -quality improvement -safety -informatics

health care teams now focus on what went wrong rather than just blaming the individual clinician who executed the error.

.

Vigilance, teamwork and collaboration, high-reliability organizations, and regulatory mandates.

...

The Clinical Judgment Model involves four steps

1) noticing 2) interpreting 3) responding 4) refecting

The Future of Nursing Recommendations

1. Remove scope-of-practice barriers. 2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. 3. Implement nurse residency programs. 4. Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. 5. Double the number of nurses with a doctorate by 2020. 6. Ensure that nurses engage in lifelong learning. 7. Prepare and enable nurses to lead change to advance health. 8. Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data.

Problem Solving

1.Is it important? 2.Do I want to do something about it? (e.g., Do I "own" the problem?) 3.Am I qualified to handle it? 4.Do I have the authority to do anything? 5.Do I have the knowledge, interest, time, and resources to deal with it? 6.Can I delegate it to someone else? 7.What benefits will be derived from solving it?

Critical thinking

A composite of knowledge, attitudes, and skills; an intellectually disciplined process. Also, the ability to assess a situation by asking open-ended questions about the facts and assumptions that underlie it and to use personal judgment and problem-solving ability in deciding how to deal with it.

Satisficing

A decision process where the solution is acceptable (rather than best). the decision maker selects an acceptable solution, one that may minimally meet the objective or standard for a decision. This approach allows for quick decisions and may be the most appropriate when lack of time is an issue.

Sentinel event:

A sentinel event is an unexpected occurrence involving death or serious physical or psychologic injury, or the risk thereof.

Optimizing

A specific decision process that is designed to produce the best (optimal) results. decision maker selects the option that is best, based on an analysis of the pros and cons associated with each option.

(AHRQ)

Agency for Healthcare Research and Quality (AHRQ): "The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management."

(AHRQ)

Agency for Healthcare Research and Quality: The primary federal agency devoted to improving quality, safety, efficiency, and effectiveness of health care. AHRQ is also the source for the stay healthy checklists for men and women

(ABQAURP)

American Board of Quality Assurance and Utilization Review Physicians: A multidisciplinary professional organization that focuses on those providers in roles related to quality assurance and utilization review. provides a certification program for physicians, nurses, and other healthcare professionals.

Near miss

An error or commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance

QSEN

An example of what is expected in communication is this: Analyze differences in communication style preferences among patients and families, nurses and other members of the health team Describe impact of own communication style on others Discuss effective strategies for communicating and resolving conflict Communicate with team members, adapting own style of communicating to needs of the team and situation Demonstrate commitment to team goals Solicit input from other team members to improve individual, as well as team, performance Initiate actions to resolve conflict Value teamwork and the relationships upon which it is based Value different styles of communication used by patients, families and health care providers Contribute to resolution of conflict and disagreement

The Joint Commission

An organization that accredits healthcare organizations and is deemed by the Center for Medicare & Medicaid Services (CMS) as holding healthcare facilities to CMS standards.

(CMS)

Centers for Medicare & Medicaid Services (CMS) formed its no-pay policy based on NQF's identification of "never-events." In other words, CMS will no longer pay for certain conditions that result from what might be termed poor practice or events that should never have occurred while a patient was under the care of a healthcare professional.

Creativity

Conceptualizing new and innovative approaches to solving problems or making decisions.

Consensus

Consensus requires that all participants agree to go along with the final decision. However, achieving consensus does not mean that the final decision will be all participants' "first choice." When striving for consensus, ask group members if they "can live" with the decision.

If the situation is subjective, non-routine, and unstructured or if outcomes are unknown or unpredictable, the nurse leader and manager may need to take a different approach.

Creativity, experience, and group process are useful in dealing with the unknown. In these situations, it is especially important for nurse leaders to seek expert opinion and involve key stakeholders.

(DNV) /(NIAHO)

Det Norske Veritas: direct competitor of TJC, DNV/NIAHO work is based on a set of international standards known as International Organization for Standardization (ISO). The main difference between TJC and the DNV/NIAHO is that the latter surveys accredited organizations annually rather than the every three years of the TJC so that an organization has considerably more information to work with. Also, the DNV/NIAHO employs in health care the same

Two primary criteria make for effective decisions.

First, the decision must be of a high quality; that is, it achieves the predefined goals, objectives, and outcomes. Second, those who are responsible for its implementation must accept the decision.

(HROs)

High-reliability organizations- manage work that involves hazardous environments

(IHI)

Institute for Healthcare Improvement An independent organization devoted to improving patient safety and health care globally. not-for-profit Source of TCAB (Transforming Care at the Bedside) rapid cycle change projects. (theory box)

(IOM)

Institute of Medicine An organization that works outside of the federal government to provide independent, scientific advice

(ISO).

International Organization for Standardization The DNV/NIAHO work is based on this

(NIAHO)

National Integrated Accreditation for Healthcare OrganizationsSM

(NQF)

National Quality Forum A membership-based organization that sets priorities and goals for performance improvement and endorses standards for measurement. related to quality measurement and reporting

Leader

Person who demonstrates and exercises influence and power over others.

Decision making (component of critical thinking)

Purposeful and goal-directed effort using a systematic process to choose among options. The hallmark of any type of decision making is the identification and selection of options or alternatives. -defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, and evaluating the result. a decision that is just "good enough" = conservative

(QSEN)

Quality and Safety Education for Nurses Comprehensive resource, including references and video modules an institute devoted to providing resources related to the QSEN Competencies for both undergraduate and graduate practitioners. The knowledge, skills, and attitudes are defined to reflect the necessary abilities one must have to practice safely and to strive for quality. The six competencies are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

Interrelated concepts with safety include

Quality, a just culture, and a culture of safety, human factors Vigilance, teamwork and collaboration, high-reliability organizations, and regulatory mandates.

___________, and subsequently __________, should drive such aspects of leading and managing as staffing and budgeting decisions, personnel policies and change, and information technology and delegation decisions.

Safety; quality The Joint Commission, the Det Norske Veritas (DNV), and the Magnet Recognition Program® have incorporated specific standards and expectations about safety and quality into their respective work.

Satisficing decision

Selecting an option that is acceptable but not necessarily the best option. might result if the nurse picked the rural hospital that offered a decent salary and benefit packet or the position closest to home.

Optimizing decision

Selecting the ideal solution or option to achieve goals. more likely to occur if the nurse lists the pros and cons of each position being considered, such as salary, benefits, opportunities for advancement, staff development, mentorship programs, and career goals.

(SWOT) analyses in the decision-making process

Strength, Weakness, Opportunity, Threat

SKIN bundle

Surface selection, Keep turning, Incontinence management, Nutrition.

TeamSTEPPS

TeamSTEPPS A teamwork system designed to increase patient safety especially communication. The curriculum includes special foci on patients with limited English skills, those in long-term care, and those who receive primary care. This site also provides a rapid response team curriculum.

(NPSF)

The National Patient Safety Foundation (NPSF) is an independent, nonprofit organization with a mission to improve the safety of care for all patients. defines patient safety as the prevention of health care errors, and the elimination or mitigation of patient injury caused by health care errors.

Magnet Recognition Program®

The only national designation built on and evolving through nursing research that is designed to recognize nursing excellence of healthcare organizations through a self-nominating, appraisal process A designation built on and evolving through research Emphasizes outcomes

SAFETY

The prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors -identify causes of errors -safety is for concern of myself and patient

Problem solving (component of critical thinking)

Using a systematic process to solve a problem

levels of errors

adverse event- unintended harm near miss- error of commision or omission that could have harmed pt. sentinel event- unexpected occurrence- death or serious injury

Values

affect all aspects of decision making, from the statement of the problem/issue through the evaluation. Values, which are influenced by an individual's cultural, social, and philosophical background, provide the foundation for one's ethical stance.

nominal group technique

allows group members the opportunity to provide input into the decision-making process.Participants are asked to not talk to each other as they write down their ideas to solve a predefined problem or issue. The advantage of this technique is that it allows equal participation among members and minimizes the influence of dominant personalities.

ethical decision making

alternatives or options identified in the decision-making process are evaluated with the use of ethical resources. The resources that can facilitate ethical decision making include : institutional policy; principles such as autonomy, nonmaleficence, beneficence, veracity, paternalism, respect, justice, and fidelity; personal judgment; trusted co-workers; institutional ethics committees; and legal precedent.

(chapter 6) Autocratic

an authoritarian style that places control within one persons position. results in more rapid decision making and is appropriate in crisis situations.

Strategies to minimize the problems encountered with group decision making and problem solving include techniques such as

brainstorming, nominal group techniques, focus groups, and the Delphi technique.

Brainstorming

can be an effective method for generating a large volume of creative options. list all ideas as stated without critique or discussion.

Delphi technique

collecting and summarizing opinions and judgments on a particular issue from respondents, such as members of expert panels, through interviews, surveys, or questionnaires. The procedure includes anonymous feedback, multiple rounds, and statistical analyses.

vital skill set for nurses is to

communicate observations or concerns related to hazards and errors to patients, families, and the health care team.

QSEN

defines safety: "minimizes risk of harm to patients and providers through both system effectiveness and individual performance."

The phases of the decision-making process include

defining objectives, generating options, identifying advantages and disadvantages of each option, ranking the options, selecting the option most likely to achieve the predefined objectives, implementing the option, evaluating the result. The challenge in this work is weighing the advantages and disadvantages.

Criteria

determined by the decision makers, may include time required, ethical or legal considerations, equipment needs, and cost

QSEN

essential knowledge, skill, and attitude objectives

Spradlin offers a four-step model:

establish the need for a solution, justify the need, contextualize the problem, and write a problem statement.

Adverse event:

event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient

(FMEA)

failure mode effects analysis

improve communication

hand of report SBAR call out check back team STEPPS

The most common cause for failure to resolve problems is

improper identification of the problem/issue

Using the SWOT analysis

individual or team lists the Strengths, Weaknesses, Opportunities, and Threats related to the situation under consideration

Factors of decision making

internal: include variables such as the decision maker's physical and emotional state, personal philosophy, biases, values, interests, experience, knowledge, attitudes, and risk-seeking or risk-avoiding behaviors. external: include environmental conditions, time, and resources. Decision-making options are externally limited when time is short or when the environment is characterized by a "we've always done it this way" attitude.

A just culture

is one where people can report mistakes or errors without reprisal or personal risk people are not punished for flawed systems

scope of errors

latent- long term (blunt end) ex:systems level/ error reporting analysis -ex: medication admin. and fall prevention. A latent failure is a flaw in a system that does not immediately lead to an accident, but establishes a situation in which a triggering event may lead to an error. active- during the process of (sharp end): a nurse who administers the incorrect medication because of a failure to check the medication order is involved in an active error

In work settings, problems often fall under certain categories that have been described as the four M's:

manpower, methods, machines, and materials.

The informative model

offers the staff the ability to make a decision after the information has been shared and without the active involvement of the manager.

three distinct models: paternalistic, informative, and shared decision making

paternalistic model the managers decide what is best for their team. The informative model offers the staff the ability to make a decision after the information has been shared and without the active involvement of the manager. In a shared decision model, the decisions are made through an interactive, deliberate process and the staff may express and discuss options and preferences. The shared decision model has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction.

The decision-making style of a nurse manager can be conceptualized using three distinct models:

paternalistic, informative, and shared decision making

Additionally, specifically focused efforts such as those of the Quality and Safety Education for Nurses (QSEN) and TeamSTEPPS initiatives, have addressed

patient safety issues

STEEP

quality care is safe, timely, effective and efficient, equitable, and patient centered.

The autocratic decision-making method

results in more rapid decision making and is appropriate in crisis situations.

(RCA)

root cause analysis

Porter-O'Grady the three essential components to effective problem solving within organizations are

tactical methods strategic approaches cultural changes

In a culture of safety, the focus is

teamwork

Three major driving forces are behind the current emphasis on quality:

the IOM, the Agency for Healthcare Research and Quality (AHRQ), and the National Quality Forum (NQF)

To Err is Human: Building a Safer Health System (2000), produced by.........

the Institute of Medicine (IOM)

shared decision model,

the decisions are made through an interactive, deliberate process and the staff may express and discuss options and preferences. The shared decision model has been shown to increase work performance and productivity, decrease employee turnover, and enhance employee satisfaction.

paternalistic model

the managers decide what is best for their team.

Define the problem, issue, or situation Gather Data Analyze Data Develop Solutions Select a Solution Implement the Solution Evaluate the Result

the problem solving process

Clinical reasoning

the process by which nurses make their judgments (e.g., the decision-making process of selecting the most appropriate option)

Some decisions are "givens"

they are based on firmly established criteria in the institution, which may be based on the traditions, values, doctrines, culture, or policy of the organization.

focus groups

to explore issues and generate information. Focus groups can be used to identify problems or to evaluate the effects of an intervention. The groups meet face-to-face to discuss issues. Under the direction of a moderator or facilitator, participants are able to validate or disagree with ideas expressed.

true or false 98,000 patients die each year due to medical mistakes that could have been prevented

true always use evidence based care and identify your patient! - use at least 2 ways

Majority rule

when 100% agreement cannot be achieved.

Competencies of Health Professionals

• Provide patient-centered care • Work in interdisciplinary teams • Employ evidence-based practice • Apply quality improvement • Utilize informatics

To Err is Human spelled out six major aims in providing health care

• Safe • Effective • Patient-centered • Timely • Efficient • Equitable

"Five Steps to Safer Health Care,"

•Ask questions if you have doubts or concerns. •Keep and bring a list of ALL the medicines you take. •Get the results of any test or procedure. •Talk to your doctor about which hospital is best for your health needs. •Make sure you understand what will happen if you need surgery.

TANNERS 5 FACTORS influence decision making.

•Clinical judgments are more influenced by what nurses bring to the situation than the objective data about a situation. •Sound clinical judgment rests, to some degree, on knowing the patient and the patient's typical pattern of responses, as well as engaging with the patient and identifying the patient's concerns. •Clinical judgments are influenced by the context in which a situation occurs and the culture of the nursing care unit. •Nurses use a variety of reasoning patterns alone or in combination. •Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.

The six competencies of QSEN

•patient-centered care, •teamwork and collaboration, •evidence-based practice, •quality improvement, •safety, •informatics.

(AHRQ) strongly encouraged (n=10) or encouraged (n=12).

•strongly encouraged practices: • preoperative checklists, •bundles to prevent central line-associated bloodstream •infections, •interventions to reduce urinary catheter care •, hand hygiene, •"do not use" abbreviations, •barrier precautions to prevent healthcare-associated bloodstream infections Encouraged •. Multicomponent interventions to reduce falls •. Documentation of patient preferences for life-sustaining treatment •. Team training •. Rapid response systems •. Use of simulation exercises in patient safety efforts

Through the Magnet Recognition Program® Model Five elements comprise the model (focuses on quality care.)

•transformational leadership; •structural empowerment; • exemplary professional practice; •new knowledge, innovation, and improvements • empirical quality results.