1. what is the AHRQ?
Answer
the agency for Healthcare research and quality
2. what did the AHRQ establish?
Answer
TeamSTEPPS which stresses communication
3. what is the ISMP?
Answer
the institute for safe medication practices
4. what does the ISMP do?
Answer
investigate medicine errors, why they happen, and how to prevent them
5. what is the IOM
Answer
Institute of Medicine
6. what does the IOM do?
Answer
reports about patient safety, how to improve patient safety, and why errors occur
7. what is the IOM currently called?
Answer
National Academy of Sciences, Engineering, and Medicine
8. what is QSEN?
Answer
,Quality and Safety Education for Nurses
9. what does QSEN do?
Answer
it is the framework supporting pre-license education, establishes what competencies students
need upon graduation; supports safety and patient care in pre-licensed nurses, gives 6
competencies, sets Knowledge Skills and Attitudes (KSAs) for each competency which must be
met before graduation
10. who made the report to err as human?
Answer
IOM
11. when was to err as human reported?
Answer
1999
12. What did to Err as Human do?
Answer
brought patient safety to the forefront in the US; showed that errors cost the hospitals money;
established a connection between quality care and patient safety; determined that PREVENTING
DEATH AND INJURY FROM MEDICAL ERRORS REQUIRES LARGE SYSTEM-WIDE
CHANGES
13. what did to Err as Human create?
Answer
the National Center for Patient Safety within the AHRQ
14. what does the National Center for Patient safety focus on?
Answer
STRICTLY patient safety
15. what does the National Center for Patient Safety establish?
Answer
requires mandatory and voluntary reporting systems; defines the role of consumers, profes-
sionals, and accreditation, BUILDS A SAFETY OF CULTURE
, 16. what are the 6 competencies of QSEN?
Answer
patient centered care teamwork and collaboration
evidence based practice quality improvement safety
informatics
17. what is the science of safety and what does it say?
Answer
it minimizes risk of harm to the patients and establishes that human error is bound to happen.
Says that you can control the human factors
18. what is an adverse event?
Answer
injury caused by medical care - umbrella event
19. what is an adverse drug event?
Answer
adverse event involving medication use; a specific AE relating to medications
20. what is a sentinel event?
Answer
an AE that causes DEATH or SERIOUS HARM to the patient; not usually anticipated or
expected
21. what is a medication error?
Answer
a preventable event related to prescribing (NP, physician), dispensing (pharmacist), and/or
administering (nurse) medications
22. what is root cause analysis?
Answer
structured process identifying contributing fac- tors underlying an AE
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