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Betsy Lehman Centre Nursing Quality & Safety in Healthcare NUR 2833 Keiser Univeristy

WEEK 3 WRITE IT DOWN 2 Betsy Lehman Centre 1) What are the six most critical elements of learning identified by the Dana-Farber Cancer Institute (DFCI) following a ten-year patient safety journey? The six most critical elements of learning identified by the Dana-Farber Cancer Institute following a ten-year safety journey are A) The engagement of all leadership, including trustee, clinical, academic and administrative, 2) Vigilance, i.e., the preoccupation with the possibility of error and constant vigilance to safe practice, 3) Patient -centered and family care, 4) Victims, 5) Systems, and 6) Interdisciplinary practice and teamwork. Learning from Medical Errors 2) Learning from medical errors. Clinicians share their stories describing errors that still haunt them today and point out ways that those errors could have been prevented. Dr. Allan Frankel lists, “…So many things that could [have been] different”. What are three things that could have been better? Three things that could have been different would be teamwork, planning and communication. Respond to the following relating to IHI PS 101 Course Summary 3) Institute for Healthcare Improvement (IHI) Patient Safety (PS) 101: Introduction to Patient Safety, Lesson 1: Understanding medical Error and Patient Safety a. From both individuals and the organizations working in healthcare, identify the three commitments that are needed to make dramatic improvements in patient safety. 

Acknowledge the scope of the problem of medical errors and make a clear commitment to redesign systems to achieve unprecedented levels of safety.

WEEK 3 WRITE IT DOWN 3 

Recognize that most patient harm is caused by bad systems and not bad people, and therefore we must end our historic response to medical error, which has been saddled with finger-pointing and shame.

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Acknowledge that individuals alone cannot improve safety; it requires everyone on the care team to work in partnership with one another and with patients and families.

4) Institute for Healthcare Improvement (IHI) Patient Safety (PS) 101: Introduction to Patient Safety, Lesson 2: Responding to Errors and Harm. What tool can be used to determine whether an individual is to blame in an adverse event? The James Reason “Decision Tree” is a tool that can be used to determine culpability of unsafe acts in an adverse event. Respond to the following relating to your individual Partner Collaborative Paper and Presentation Project group reading assignment: 5) Identify and discuss an additional three key points from your group’s reading assignment. In your discussion include the reasoning and the significance of the reading context and how it relates to quality and safety in healthcare. a. Designing safe systems requires an understanding of the sources of errors and how to use safety design concepts to minimize these errors or allow detection before harm occurs. Essentially, this point outlines the need for the understanding of the underlying causes, or pathophysiology of errors, to fully understand how to treat or avoid them at all.

WEEK 3 WRITE IT DOWN 4 b. Messages about safety must signal that it is a serious priority of the institution, that there will be increased analysis of system issues with awareness of their complexity, and that they are endorsed by nonpunitive solutions encouraging the involvement of the entire staff. This point drives home the need for a comprehensive move toward an absolute culture of safety, beginning with an analysis of all of the systems that are in place, understanding that they are all uniquely complex. The solutions that are sought must also carry no punishments in an attempt to fully involve all staff in the effort. c. Although almost all accidents result from human error, it is now recognized that these errors are usually induced by faulty systems that “set people up” to fail. Correction of these systems failures is the key to safe performance of individuals. While acknowledging that the majority of accidents are the result of human error, it must also be recognized that these errors are usually the fault of faulty systems that have been put in place. With the correction of these systems, safe performance is attainable. 6) Page through Provision 3 of the Guide to the Code of Ethics for Nurses with Interpretive Statements while thinking about your future role as a registered nurse. Elaborate, by providing a supporting comment relating to the nurse as she/he promotes, advocates for, and protects the rights, health, and safety of the patient. After paging through the third provision of the Guide to the Code of Ethics for Nurses with Interpretive Statements while thinking about my future role as a registered nurse, I am glad to know that the protection of patient information, whistleblowing, attributes required for the nursing practice, a culture of safety, and processes to address

WEEK 3 WRITE IT DOWN 5 questionable practices are items that have been considered. These are all issues that could only enhance the nursing profession and enhance healthcare outcomes.

References Fowler, M. (2015). Guide to the Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD, USA: American Nurses Association. Institute for Healthcare Improvement. (2019, September 1). Open School. Retrieved 09 2019, from Institute fo Healthcare Improvement.org: http://www.ihi.org/education/ihiopenschool/overview/Pages/default.aspx Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err is Human: Building a Safer Health System. Washington D.C., USA: National Academy Press. Retrieved from http://nap.edu/9728...