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66 Cards in this Set
- Front
- Back
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"Why Hospitals Should Fly" |
About a theoretical hospital in which the goal was collaboration and teamwork Patient care was not doctor centered, but team centered Eliminate errors based on teamwork and barrier-less communication Gives staff sense of psychological safety |
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Why Hospitals Should Fly: Will's Experience |
Always assume you are making an error |
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Will's Conclusions |
Collaboration with caregivers is vital |
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Will's Motivation |
His best friend's son died in the hospital where he was head administrator *Patient safety= ultimate motivation |
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Guiding Principles at St. Michael's Hospital |
-Hospital wide agreement and the commitment of everyone to discard the old ways and construct an entirely new method of how heath care is done -Need to assume the worst to protect the patient -3 causes of human errors: perception, assumption, and communication -All medication orders are lethal until proven otherwise |
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Tenerife-Latent Error |
deadliest accident in aviation history caused by miscommunication and flawed assumptions |
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Tenerife Captain Actions |
Captain was very experienced and anxious to get in the air Co-pilot did not get the signal to take off; pilot ignored it and crashed into another airplane in his path Multiple fatalities |
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Cause of Disaster |
A plane crash Flawed assumption Misinterpretation that the pilot knew what he was doing and "inability" to question the pilot |
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Disaster Metaphor |
Metaphoric to nursing errors--> a flight attendant (symbolizing surgeon) was too intimidating to his colleagues to be corrected when he started to take off without the "OK" and he crashed into another plane on the runway killing 500 peopleMetaphor= nurses are too intimidated by surgeons to correct their mistakes |
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Errors |
Failure of planned actions to be completed as intended or the use of wrong plans to achieve what is intended |
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Major Cause of Errors |
perception, assumption, botched communication, mistakes increase when people are in a hurry |
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Individual Responsibility of Errors |
Bad outcomes as a result of bad behavior: "naming, blaming, and shaming" *Fundamental Attribution Error |
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System Accountable Errors |
"High-Reliability Organizations" The interdependent interaction of multiple human nonhuman elements in any effort to achieve a stated purpose--> "production process" |
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Error Contributing Factors |
Human error, commission of active failures (giving the wrong medication), creation of latent conditions (running out of sterile gloves) Increased workload due to patient turnover, high staff turnover (everyone is new), long work hours, rapid increase in knowledge and technology, increased interruptions and demands on nurses' time Acutely ill patients, shorter hospital stays--> less time to teach, no data on quality, decrease in nurses |
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Types of Errors |
Failures of planned actions to be completed as intended, use of wrong plans to achieve what is intended -Latent -Blatant |
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Latent Error |
Arise from factors in the system that are not in control of the workers such as poor design of work or equipment, inadequate training, insufficient supplies, inappropriate deployment of staff |
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Blatant Error |
Obvious Error |
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Adverse Errors |
Injuries caused by medical intervention, as opposed to the health condition of the patient Preventable adverse: when adverse event is result of an error |
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How to Minimize Errors |
Create collegial interaction team, which require mutual support and caring and barrier-free communication is essential We need to acknowledge both the individual and the system we aim for changes to make patient safety a top priority Nurses are the larges component in the healthcare work Force--> CRITICAL ROLE Assessment, monitoring, patient care Nursing care and observation of physical and cognitive changes |
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Latent vs Active Failure |
Active: Front line errors (nurses, physicians) caused by forgetting, not communication, misinterpretation of data, not the right procedure--> consequences immediately apparent 1. "sharp end" of an error: consequences are immediately apparent 2. giving the wrong medication Latent: factors in the system that are not in control of the workers; poor design of work or equipment, not enough training or supplies. Due to decisions made by people at the "blunt end" of the organization 1. inadequate staff orientation, training and competency; breakdown in communication 2. arise from strategic and other top-level decisions made by people at the "blunt end" of an organization 3. running out of sterile gloves |
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System Failure |
70-90% of errors result from badly designed systems 40% of unanticipated deaths occur on medical/surgical units |
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"Failure to rescue" |
Signs of deterioration are missed or actions are not taken to restore patients to a healthy state Concept has been tested and validated as an indicator of the quality of acute hospital care Higher levels of staffing present--> incidence of failure to rescue is reduced |
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IOM Quality Improvement Goals |
Safe, effective, patient centered, timely, efficient, equitable |
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IOM Quality |
Doing the right thing, at the right time, in the right way, for the right people and having the best possible results Should not differ because of education, disability, sexual orientation, ethnicity, language, or location of residence QSEN: patient-centered, evidence-based practice, quality improvement, safety, informatics |
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IOM Effective |
Evidence based practice: clinical decision making to promote the best patient outcome |
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IOM Patient Centered |
Respect for patient's values, preferences, and expressed needs Coordination and integration of care Information, communication, and education Physical comfort and emotional support (family and friends) |
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IOM Equitable |
aka FAIRNESS at the level of the individual and at the population level goal of care: improve healthcare status do so in a manner that reduces health disparities among subgorups implies universal access problems include: lack of health insurance, lack of providers, reduced amount of charity care, lack of access related to quality and outcomes |
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Quality Improvement Processes |
IOM quality improvement goal: doing the right thing at the right time in the right way for the right people and having the best possible results Lean Six sigma PDSA TCAB TPS approach |
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LEAN |
quality circles, people get together and problem solve identified needs of customer, aims to improve processes by removing non-value-added activities Sort, shine, straighten, systemize, sustain |
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Six Sigma |
Statistical measurement to reduce cost, decrease production variation, eliminate defects Teams define goals, collect data, data analysis, creative solutions and implementation, improve, quality control |
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PDSA |
Plan: state objectives, make predictions, develop plan to carry out test cycle Do: carry out tests, document problems and unexpected observations, being analysis of data Study: summarize Act: determine changes needed to be made |
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TCAB |
Transforming care at the bedside = quality improvement initiatives -new ideas for transforming the way care is delivered, doesn't solely come from hospital leaders or the quality improvement department, but from front-line nurses and other care team members---> the people who spend the most time with patients and their families -Foster transformative change and emphasizes continuous learning and discovery |
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TPS Approach (Toyota Production System) |
Related to LEAN: efficiency and quality Top down approach; workers implement Get rid of overburden, inconsistency, and eliminate waste |
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Definitions of Quality Improvement and Research |
Combined efforts by everyone to make changes that will lead to better patient outcomes, better system performance, and better development |
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Nursing Research |
Systematic investigation of phenomena related to the improvement of patient care |
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Rules for Quality Improvement |
Healing relationships, custom patient care, patient as source of control, share knowledge, evidence-based decision making, safety as system property, transparency, anticipate patient needs, decrease waste, team cooperation |
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Research Steps |
Best systematic review of descriptive and qualitative studies, next evidence from a single descriptive/qualitative study, expert opinion, expert committee, Last evidence based on quantitative approaches |
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Quality Assurance and Quality Control |
research based on quality assurance (evaluating delivery of health care) and quality control (system for verifying and maintaining a desired level of quality)
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Principle |
opportunity for improvement exists in every process on every occasion Commitment to constantly improve operations, processes and activities to meet patients needs in an efficient, consistent and cost-effective manner |
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CQI Model |
Emphasizes process and system rather than individual |
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Nurse-Patient Relationship Stages |
Orientation: getting to know you; must be mutual trust; introduce yourself and be straight forward, non-judgemental manner; truthful; agreement on what you'll work on Working: tackle tasks agreed on may be periods of work combined with periods of resistance; requires patience and therapeutic communication Termination: activities that enable nurse and patient to end relationship |
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Technology Uses |
Improve patient safety, facilitate interdisciplinary communication and independent decision making, document care and communicate with patient and other healthcare professionals, referrals |
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Technology Benefits |
more accurate payment for new procedures, few rejected claims, improved disease management, better understanding of health conditions and healthcare outcomes, harmonizing of disease monitoring and reporting worldwide, speeds process, prevents medication errors, connects healthcare team and promotes accuracy |
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Technology Disadvantages |
cost to start up, extra training, lack of knowledge about the benefits related to quality of care, lack of reimbursement for costs and resources, time and workflow impact -need to change: business practices in office, records systems from pater to electronic, staff training for change |
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Health Literacy |
The ability to read and understand and act on health information Affects patient care: when people can't understand what you are trying to teach them about themselves--> impacts health Literacy: ability to read, understand, and act on health info can't read: medication errors, increased risk of hospitalization, can't comply with treatment Strong indicator of health status, increases the disparity in healthcare access among vulnerable populations, healthcare costs are 4x higher, problem with patient compliance, only about 50% of people take medication as directed, patients have less knowledge of their disease and fewer self-management skills |
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Health Disparities |
Impact on care: unhealthy behavior, violence, financial hardship --> can't afford healthcare, lower rates of health insurance and regular health care provider visits, reduces access to health care High risk of hypertension, cardiovascular and cerebrovascular disease cancers, diabetes, HIV, unintentional injuries, SIDS, and homicide Genetics does NOT contribute, only SES (social economic status) |
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Disparities |
Differences between people and groups that affect how frequently a disease affects a group, how many people get sick, how often disease causes death Racial and ethnic minorities, rural areas, women, children, elderly, people with disabilities |
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Cultural Competence |
Respect the individuals's beliefs, practices and backgrounds allow health care practitioner to make exact diagnosis Consider non-verbal communication, which is not universal, gestures mean different things Need to monitor responses and adjust ask for input Seek consultation from bicultural colleagues Always ask patient what their preferences is and don't generalize |
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What Makes a Good Team? |
a group of people who can work together to achieve a common goal -share goals -contributors are valued/value each member communication know your members equal participation/contribution |
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Effective Teams |
Communicate, collaborate, full of initiative, visionary, able to adapt, constructive, organized, focused (goal-oriented), get it done Teamwork: establish objectives, develop participatory style, focus on contributions, organize meetings and the team |
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Characteristics of Effective Teams |
Unity of purpose The group understands its own operations The atmosphere is informal There is a log of discussion Everyone participates People are not afraid to propose "dumb" creative ideas People are free to express ideas and feelings There is disagreement and this is viewed as good Most decisions are made at a point where there is general agreement Each individual carries his/her own wight Criticism is frequent, frank and relatively comfortable The leadership of the group shifts from time to time Not hierarchial |
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Total number and Cost of Medical Errors |
100,000 annual deaths, total annual cost is 50 billion dollars |
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Sue Sheridan: Cause of Errors in Case of Son and Husband |
Sheridan became involved in patient safety after her family experienced two serious medical system failures. her husband, pat, died in 2002 after diagnosis of spinal cancer failed to be communicated Son, Cal, suffered brain damage --> Kernicterus - five days after birth in 1995 when neonatal jaundice went untreated |
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New Patient Safety Goal for 2014 |
Alarm Management |
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Benner's Stages (1984) |
Novice advanced beginner competent practitioner proficient practitioner expert practitioner |
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Cohen's Model (1981) |
Stage I: unilateral dependence Stage II: Negativity/independence Stage III: dependence/mutuality Stage IV: Interdependence |
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Socialization into Nursing |
Reading Journals Talking to other nurses |
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Medicare |
Social insurance program that provides health insurance for americans aged 65 and older who have worked and paid into the system Does also provide younger people with disabilities |
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Medicaid |
social health care program for families and individuals with low income and limited resources "persons of all ages who's income is insufficient to pay for health care" |
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Affordable Care Act |
The Patient Protection and Affordable Health Care Act and Education Reconciliation Act ensure that 95% of americans have access to quality, affordable health care will reduce the deficit by $143 million over the next 10 years with further deficit reduction the following decade Also will make college more affordable through changes in the student loan program Prohibits insurers from having lifetime limits on coverage Extends coverage to age 26 Prohibits recession of coverage except in fraud Caps administrative expenses Creates health care insurance changes Tax credits, out of pocket maximums to benefit low income Extends Medicaid eligibility |
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Beliefs |
health beliefs are perceptions of how a behavior affects the person and their perceived vulnerability Nurses must examine beliefs and come to terms with beliefs on issues: end of life, abortion, alternative lifestyles, refusal of treatment, alternative therapies and similar issues |
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Three Main Types of Beliefs |
1. Descriptive or existential 2. Evaluative beliefs 3. Prescriptive (encouraged) and Proscriptive (prohibited) |
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Ethics |
Subset of philosophy The science or study of moral values A system of principles concerning the actions of a nurse in his/her relationships with patients, family members, other health care providers or society as a whole |
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Nursing Philosophies |
Individual Philosophy: based on values -look at what you believe -look at what you value -combine them into a personal philosophy of nursing -write it out and review it as you move through the program Creative philosophy -profession: ANA social policy statement -institutional: college of nursing mission statement |
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Cultural Competence |
Knowledge of patients culture directs the nurse in understanding behaviors and planning appropriate approaches to patient problems Culture influences assessment, determines patients culturally specific needs |
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Barriers to Cultural Competence |
Stereotyping: attributing characteristics to all members of an ethnic group; "pigeon holing" Ethnocentrism: perception that ones own ethnic group is best Denial: doesn't recognize cultural differences Defense: recognizes differences but sees them as negative Minimization: unaware of projection or own cultural values and sees own values as superior Denial: doesn't recognize cultural differences Culture: the norms and practices of a particular group that are learned and that guide thinking, decision, and actions |
