safety - ANS refers to the prevention of health care errors and the elimination or mitigation of patient injury caused by health care errors.
types of health care errors: - ANS error of commission; error of omission; error of execution
types of errors: - ANS diagnostic...
safety - ANS refers to the prevention of health care errors and the elimination or mitigation
of patient injury caused by health care errors.
types of health care errors: - ANS error of commission; error of omission; error of execution
types of errors: - ANS diagnostic; treatment; preventative; diagnostic
levels of errors: - ANS adverse event; near miss; sentinel event
error of commission - ANS doing the wrong thing
error of omission - ANS not doing the right thing
error of execution - ANS doing the right thing incorrectly
adverse event - ANS unintended harm by an act of commission or omission rather than as
a result of a disease process
near miss - ANS error of commission or omission that could have harmed a patient, but
harm did not occur as a result of chance
sentinel event - ANS unexpected occurrence involving death or serious injury
why are many errors undocumented or are not reported? - ANS due to staff fear of reprisal,
lack of adequate systems to report, limited staff education about safety and report process
blunt end - ANS latent errors; organizational/system
sharp end - ANS active errors; direct patient care
culture of blame - ANS previously existed; identified clinician at fault, followed by
disciplinary measures
culture of safety - ANS focus on what went wrong rather than who to blame; needed to
address errors and to prevent a reoccurrence; look at what happened as opposed to who did it
,just culture - ANS seeks to find a balance between the need to learn from mistakes and the
need for disciplinary action against employees
there has to be a balance between what when it comes to errors? - ANS blame and
accepting responsibility and learning from mistakes
concept attributes to safety - ANS knowledge; skills; attitudes
knowledge concept attribute of safety - ANS focus of safety is on the execution of skills, as
well as on technology and systems level; human factors, not just skills
skills concept attribute of safety - ANS nurses need to use tools to contribute to safer
systems
attitudes concept attribute of safety - ANS nurses and other health care professionals need
to value their roles in safety and collaboration; Nurses' personal and professional attitudes are
instrumental in shaping their nursing practice and recognizing the cognitive and physical limits
of human performance
QSEN competencies: - ANS patient-centered care; teamwork and collaboration;
evidence-based nursing practice; quality improvement; informatics; safety
QSEN project - ANS has been the national leader in defining the competencies for safety
by specifying the knowledge, skills and attitude objectives for all nurses including pre-licensure
and graduate students
As nurses how do we address /prevent the safety factors that place individuals at risk? - ANS
the nurse's role in prevention is largely educative; observation or prediction of potentially
harmful situations so that harm can be avoided; client education that empowers clients to
protect themselves and their families from injury
desired outcomes of addressing/preventing the safety factors that place individuals at risk: -
ANS acquisition of knowledge of hazards; behaviors that incorporate safety practices; skills
to perform in the event of certain emergencies
examples of desired outcomes: - ANS describe methods to prevent specific hazards; report
use of home safety measures; alter home physical environment to reduce risk of injury; describe
emergency procedures for poisoning and fire; describe age-specific risks or work safety risks or
community safety risks; demonstrate correct use of child safety seats; demonstrate correct
administration of CPR; today focus on point of care safety related to falls and restraint use
The Joint Commission National Patient Safety Goals 2016 Long Term Care: - ANS identify
residents correctly - use at least 2 ways to ID residents; use medicines safely - take extra care
, with anticoagulants and record and pass along correct info about residents' medication; prevent
infection - had hygiene and prevention of central line infections; prevent residents from falling -
fall risk assessment; prevent bed sores - skin assessment
who is more at risk for falls? - ANS elderly and infants
who is more at risk for ulcers? - ANS bed bound, immobile
The Joint Commission National Patient Safety Goals 2016 Hospital: - ANS identify patients
correctly - at least 2 identifiers; improve staff communication - get test results to the right staff
person on time; use medicines safely - label medications before a procedure, use caution with
blood thinners, record and pass along correct infor about patient meds; use alarms safely -
make improvements to ensure that alarams on medical equipment are heard and responded to
one time; prevent infection; identify patient safety risks - find out which patients are most likely
to commit suicide; prevent mistakes in surgery - assure correct surgery is done on the correct
patient and the correct place on the patient's body
point of care exemplars of safety: - ANS prevention of decubitus ulcers; medication
administration; fall prevention; communication; restraint use; seizure precautions; hypothermia
and hyperthermia
systems level exemplars of safety: - ANS documentation/electronic records; error reporting;
work processes; care coordination; team systems
common care-management problems: - ANS failure to monitor, observe, or act; delay in
diagnosis; incorrect assessment of risk; loss of info during transfer to other healthcare staff (and
off reports); failure to note faulty equipment; failure to carry our preoperative checks; deviation
from an agreed protocol without clinical justification; failure to seek help when necessary; use of
incorrect protocol; treatment given to wrong body site
normal urine output - ANS 30 mL/hr
when do you treat for pain? - ANS ranked 5 or more out of 10
risk factors for falls - ANS poor vision; cognitive dysfunction; impaired gait or balance;
difficulty getting in and out of chair; orthostatic hypotension; urinary frequency or diuretics;
weakness from disease, injury, or therapy; medications; history of falls
what is the leading cause of injury in older adults? - ANS falls
what is the most frequently reported adverse event in adult inpatient settings? - ANS falls
where do falls occur the most? - ANS in the home
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