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66 Cards in this Set

  • Front
  • Back

"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

Why Hospitals Should Fly: Will's Experience

Always assume you are making an error

Will's Conclusions

Collaboration with caregivers is vital

Will's Motivation

His best friend's son died in the hospital where he was head administrator

*Patient safety= ultimate motivation

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

Tenerife-Latent Error

deadliest accident in aviation history

caused by miscommunication and flawed assumptions

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

Cause of Disaster

A plane crash

Flawed assumption

Misinterpretation that the pilot knew what he was doing and "inability" to question the pilot

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


Failure of planned actions to be completed as intended or the use of wrong plans to achieve what is intended

Major Cause of Errors

perception, assumption, botched communication, mistakes increase when people are in a hurry

Individual Responsibility of Errors

Bad outcomes as a result of bad behavior: "naming, blaming, and shaming"

*Fundamental Attribution Error

System Accountable Errors

"High-Reliability Organizations"

The interdependent interaction of multiple human nonhuman elements in any effort to achieve a stated purpose--> "production process"

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

Types of Errors

Failures of planned actions to be completed as intended, use of wrong plans to achieve what is intended



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

Blatant Error

Obvious Error

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

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

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

System Failure

70-90% of errors result from badly designed systems

40% of unanticipated deaths occur on medical/surgical units

"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

IOM Quality Improvement Goals

Safe, effective, patient centered, timely, efficient, equitable

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

IOM Effective

Evidence based practice: clinical decision making to promote the best patient outcome

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)

IOM Equitable


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

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


Six sigma



TPS approach


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

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


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


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

TPS Approach (Toyota Production System)

Related to LEAN: efficiency and quality

Top down approach; workers implement

Get rid of overburden, inconsistency, and eliminate waste

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

Nursing Research

Systematic investigation of phenomena related to the improvement of patient care

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

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

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)


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

CQI Model

Emphasizes process and system rather than individual

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

Technology Uses

Improve patient safety, facilitate interdisciplinary communication and independent decision making, document care and communicate with patient and other healthcare professionals, referrals

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

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

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

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)


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

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

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


know your members

equal participation/contribution

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

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

Total number and Cost of Medical Errors

100,000 annual deaths, total annual cost is 50 billion dollars

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

New Patient Safety Goal for 2014

Alarm Management

Benner's Stages (1984)


advanced beginner

competent practitioner

proficient practitioner

expert practitioner

Cohen's Model (1981)

Stage I: unilateral dependence

Stage II: Negativity/independence

Stage III: dependence/mutuality

Stage IV: Interdependence

Socialization into Nursing

Reading Journals

Talking to other nurses


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


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"

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


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

Three Main Types of Beliefs

1. Descriptive or existential

2. Evaluative beliefs

3. Prescriptive (encouraged) and Proscriptive (prohibited)


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

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

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

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