1. NASEM
Answer
National Academies of Sciences, Engineering, Medicine
2. AHRQ
Answer
Agency for Healthcare Research and Quality
Team strategies and Tools to enhance performance and patient safety( teamstepps)
3. QESN
Answer
Quality and Safety Education for Nurses
4. ISMP
Answer
Institute for Safe Medication Practices
5. To err is human
Answer
challenged the healthcare system to focus on medical errors
6. TeamSTEPPS
Answer
Team Strategies and Tools to Enhance Performance and Patient Safety
7. QESN goals
Answer
Patient Centered Care
- Including pts/families in all healthcare decision making
,• Teamwork and Collaboration
- SBAR / Rapid Response Teams
• Evidence Based Practice
- Bundles and Protocols
• Quality Improvement
- Culture of Safety
• Safety
- Medical Reconciliation - Warm Handoffs
• Informatics
- Use of Databases and Dashboards
8. AHRQ goals
Answer
Produce evidence to make health care safer, higher quality, more accessible, equitable, and
affordable
• Works within the U.S. Department of Health and Human Services and with other partners to
make sure that the evidence is understood and used
• TeamSTEPPS - training to improve teamwork and communication - AHRQ Initiative
9. Leadership Strategy
Answer
Planning, problem solving, process improvement
10. Planning/Brief
Answer
short session prior to start to discuss team formation; assign roles, establish expectations and
climate and to attempt to anticipate outcomes and likely contingencies
11. problem solving/ huddle
Answer
ad hoc planning to re-establish situational aware- ness, reinforcing plans already in
place and assessing need for any adjustments
12. Process improvement/debrief
Answer
,informal information exchange session de- signed to improve team performance and
effectiveness; after action review
13. situation monitoring process
Answer
is the process of continual scanning your envi- ronment - what's going on around you -
Situational Awareness
Creates shared mental model so all are on the "same page" Occurs during a
procedure or event.
Should precede mutual support and be used by all team members
14. TeamSTEPPS - STEP
Answer
is a tool for monitoring situations in the delivery of health care.
Status - Pt Hx, VS, Meds, PE, Plan of Care, ?Psych Issues Team - Fatigue, Workload, Task
Performance, Skill, Stress
Environment - Facility Info, Admin Info, Human Resources, Ability to Triage Acuity. Equipment
Progress - What is the status of Team's pts, Do we have established goals for the Team?, What
are the Teams tasks / priority actions, Evaluate - is plan still appropriate?
15. Cross monitoring
Answer
Team Members can employ an error reduction strategy that is called CROSS MONITORING
- Monitoring actions of other team members to provide a safety net within the team
- "Watching each other's back"
Team members can also use the communication tool known as a Check-back to confirm or
question an action or order.
S-stress
A-Alcohol/drugs F-fatigue
E-eating and elimination
, 17. ISMP goals
Answer
Goal is to advance patient safety worldwide by empowering the healthcare community,
including consumers, to prevent medication errors Collect & analyze reports of near-misses,
medication errors, and adverse drug events.
Disseminate current medication safety information and error-prevention strategies to educate
HCP and consumers.
Advocate the adoption of safe medication standards by accrediting bodies, manu- facturers,
policy makers, regulatory agencies, and standards-setting organizations. Conduct research to
provide evidence-based safe medication practices.
18. Effects of Safety Regulations/Guidelines
Answer
Policy changes
- Institutional
• Bar code scanning • Safety huddles
- Regulatory bodies
• The Joint Commission (TJC)
- Do Not Use abbreviations • ISMP
- Safe medication administration guidelines
19. human error
Answer
Predictable
- Occurs with lapse in personal behavior
- Need to understand how mistakes are made to prevent &
- Need to understand how mistakes are made to prevent and probability of error
20. Human and system factors
Answer
Refers to the study of human behavior, abilities, limitations, and other characteristics as they
affect the design and smooth operation of equipment, systems, jobs, and work environment
(AHRQ)
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