Study guide Exam 1,MAIN PDF

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NUR 2833 Nursing Quality and Safety in Healthcare Exam #1 Study Guide 1) Goal of IOM Report a) Break status quo / cycle of inaction b) Safety gaps will not be tolerated c) Address resistance to change d) Address insurmountable barriers e) Ensure healthcare is of healing and comfort with no acceptance of harm 2) IOM Comprehensive approach to healthcare quality and safety improvement created a model which includes: a) Domains of Quality b) External Drivers (need to be balanced) 3) The domains of quality are a) Safety/Safe care processes- freedom from accidental injury b) Practice consistent with current medical knowledge (evidence based practice) c) Customization (patient centered) 4) Issues that effect safety in healthcare: a) Misuse (most common)- avoidable complication b) Overuse c) Underuse 5) The external drivers that influence quality improvement a) Regulatory and Legislative b) Economics and other incentives 6) Definition of healthcare quality (quality and safety always go together CANNOT separate) a) Processes and outcomes that meet or exceed the needs and desires of the population 7) State of healthcare 1999 a) Medical errors 8th leading cause of death, estimated as much as 98K deaths annual 8) An error is defined as the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning). They are a systems issue. a) Class of errors i) Diagnostic ii) Treatment iii) Preventative failure (e.g. monitoring or follow-up) iv) Other failure (e.g. equipment) b) Types of errors/Unsafe acts i) Error in execution (1) Slip-observable (wrote wrong drug) (2) Lapse- non observable (not remembering something) (3) Violation is unsafe act and deliberate although may feel justified ii) Error in Planning

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(1) Mistake, rule based or knowledge based- planned action was wrong, e.g. lack of knowledge or assessed incorrectly iii) Active error-felt immediate, at front line, frontline operator iv) Latent error-removed from direct control, in system, *pose greatest threat- e.g. poor design instillation, management structure c) Most common medical error is medication error 9) Why do errors happen-Systems Approach a) Multiple contributing factors b) Complex systems- System-set of independent elements, both human and nonhuman, interacting to achieve a common goal c) Any element in system may belong to other systems d) System failure- due to multiple failures that occur in an unanticipated interaction create chain of events in which faults grow and evolve e) Accident- event that involves damage to defined system that disrupts ongoing or future output of that system, an unintentional incident 10) Adverse event is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a “preventable adverse event.” a) Preventable – attributed to error b) Negligent – legal criteria c) “Near” miss events 11) Adverse Drug Events Inpatient or outpatient/community May not be error, e.g. new allergy Nonadherence 3 errors/ 1,000 orders Higher event rate in children vs. adults 12) Safety- freedom from accidental injury  Avoidance, prevention and amelioration of adverse outcomes or injuries stemming from process of healthcare  Freedom from accidental injury  Primary safety goal is to prevent accidental injury  Requires operational systems and processes that increase reliability 13) Culture of safety a) requires both leadership and employees to make a commitment to it and a perception that it is everyone’s responsibility b) required operational systems and processes that increase reliability 14) Error prevention and safety improvement require a systems approach of a) Human error b) Health care system complexity 15) Four behaviors needed to improve patient safety a) Safety protocols b) Speak up with concerns arise c) Listen 2

d) Personal care of HCP 16) IOM expected to see permanent improvement, instead; a) Degree of reliability = low b) Scale of improvement poor 17) Lewis Blackman and Betsy Lehman case studies a) Issues identified/failures of the healthcare system b) Why are families psychologically scarred after an event beyond the loss of the loved one ~ this is referred to as the second adverse event 18) Deming’s theory of profound knowledge  Interconnectivity System  Special Variation  Theories of Knowledge  Human Behavior/Psychology 19) IHI Framework of Safe Reliable Care

20) Model of Improvement a) Three crucial initiation goals i) Set aims ii) Establish measures iii) Select changes b) Guide change to evaluate if improvement is actualized (PDSA) i) Plan ii) Do 3

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iii) Study iv) Act DEPOSE framework to identify source of failure in system a) Design b) Equipment c) Procedures d) Operators e) Supplies and materials f) Environment Reliable industries a) Commitment to safety b) High levels of redundancy in personal and safey measures c) Strong organizational culture for learning and willingness to change Healthcare complex system which requires increase a) Defenses (building of defenses) b) Simplification and standardization c) Redundancy (building redundancy) d) Backup systems e) Design and team performance (organizational design) f) Preconditions-Identification of latent system failures (errors) built into system need to be indentified versus focus on active errors Centers for Patient Safety (CPS under AHRQ) objectives a) Develop leadership b) Establish goals c) Track progress d) Expand safety knowledge, evidence based practice e) Disseminate information Error Reporting systems a) Purpose of mandatory is accountability, gain commitment to corrective action and system change, increase safety b) Voluntary complements and increases safety Benefit of reporting a) Increase safety b) Prevent recurrence c) Provide feedback and disseminate info d) Detect unusual events e) Increase analytical power f) Detects trends g) Increases response time Harm-Caused by systematic failures in the presence of a hazard Harm is easier to study and evaluate improvement than errors Just Culture- individuals should not be held accountable for system failing and that active errors represent human interaction within the system they work, distinguish between human error, at risk

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behavior and reckless behavior, consistently determine actions to take following an event and improve understanding of events. Swiss cheese model- cheese is layers of defense in system and holes represent opportunity for failure in the system (root causes) Human contributions to failures a) Leaders b) Line management c) Point of care d) Knowledge e) Schedules f) Increase technology g) Culture Efforts to improve safety a) Focus on harm b) Redefine harm in healthcare to include omissions, psychological and financial harm c) Make safety pervasive d) Vigilance e) Embrace system design f) Develop partnerships g) Address patient and family confidence h) Learn safe care is never finished Joint Commission National Patient Safety Goals 2020 (1) Identify patient correctly (2) Improve staff communication (3) Use medicines safety (4) Use alarms safety (5) Prevent infection (6) Identify patient safety risks (7) Prevent mistakes in surgery b) Highest priority patient safety issues c) Address how best to address the issues Nursing strategies to increase medication safety a) Minimize distractions b) Prepare/plan ahead c) If interrupted, let know passing meds d) Read back verbal orders e) Communicate with team f) Question if something doesn’t seem right Factors that promote error in healthcare a) Equipment design b) Poor communication c) High workloads d) Budget and commercial pressures e) Procedures that necessitate violation 5

f) Inadequate organization g) Missing barriers and safeguards 36) IOM recommendation for Safety Systems REFERENCE WEEK 3 SLIDE 4, 5, 6 IF NEED FURTHER CLARIFICATION) a) Establish safety programs with executive responsibility i) Provide visible attention to safety, non punitive ii) Incorporate safety principles, e.g. simplification, standardize iii) Establish interdisciplinary training programs b) Implement proven medication safety practices i) Decrease reliance on memory ii) Simplification iii) Standardization iv) Use constraints and forced functions v) Wise use of protocols and check lists vi) Decrease reliance of vigilance vii) Look at handoffs and multiple data entry viii) Differentiate around look-alike, sound-alike products 37) Medication Safety initiatives such as using technology, keeping concentrated medications off patient care units… 38) Norman’s 6 User Center Design for improvement- Six Strategies: a) Make things visible b) Simplify the structure of tasks c) Use affordances and natural mappings d) Use constraints or “forcing functions” e) Assume that errors will occur and to design and plan for recovery f) If applying the earlier strategies does not achieve the desired results, designers should standardize actions, outcomes, layouts, and displays.

39) Principles for design of safety a) Provide leadership- Make patient safety everyone’s responsibility Make clear assignments for and expectation of safety oversight Provide human and financial resources for error analysis and systems redesign Develop effective mechanisms for identifying and dealing with unsafe practitioners b) Respect for human limits in the Design process -design jobs for safety -Avoid reliance on memory -Use constraints and forcing functions -Avoid reliance on vigilance -Simplify key processes -Standardize work processes 6

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Promote effective team functioning o Train in teams o Include the patient in safety design and the process of care ii) Anticipate the unexpected o Adopt a proactive approach o Design for recovery o Improve access to accurate, timely information iii) Create a learning environment o Use simulations o Encourage reporting of errors and hazardous conditions o Ensure no reprisals for reporting o Develop a working culture o Implement mechanisms of feedback and learning from error iv) Other, such as benchmarking and collaboration Four steps after Harm i) Care for patient ii) Communicate with patient or family, apologize iii) Report iv) Document Investigation: REFERENCE WEEK 3, STARTING ON SLIDES 27 AND UP a) Cause and effect i) Fishbone diagram ii) The 5 Whys b) RCAc) RCA2- seeks to understand and respond to root causes, to prevent future harm i) Team ii) Risk and frequency based assessment iii) Flow diagram iv) Develop causal statements linking each cause to effect and then to event v) Develop measurable corrective action plan vi) Report Quality Gap in Heathcare due to a) Growing Complexity of Science and Technology-Science and technologies involved in health care have advanced more rapidly than our ability to deliver them safely, effectively and efficiently. ---No one clinician can retain all the information necessary for sound evidence based practice. b) Increase in Chronic Conditions-People live longer. -Advances in science and technology. -Aging Population c) Poorly Organized Delivery System-Health care delivery system is highly decentralized. Care delivery processes are overly complex d) Constraints on exploiting the revolution in information technology Five elements required to improve patient outcomes for the chronically ill: a) Evidence-based, planned care b) Reorganization of practices c) Systematic attention to patients’ need for information and behavioral change d) Ready access to necessary clinical expertise 7

e) Supportive information systems 44) Constraints on Exploiting the Revolution in Information Technology a) Five key areas in which information technology could contribute to an improved health care delivery system: i) Access to the medical knowledge-base ii) Computer-aided decision support systems iii) Collection and sharing of clinical information iv) Reduction in errors v) Enhanced patient and clinician communication 45) Agenda for the Future a) All health care constituencies have a shared agenda of the IOM six aims for improvement i) Safe--avoiding injuries to patients from the care that is intended to help them ii) Timely- -reducing waits and sometimes harmful delays for both those who receive and those who give care iii) Efficient --avoiding waste, in particular, waste of equipment, supplies, ideas, and energy iv) Effective--providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit v) Equitable- -providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status vi) Patient centered-providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions b) Adopt a new set of principles to guide the redesign of care processes c) Dept. HHS identify a set of priority conditions for initial focus d) HCO design and implement more effective organization support processes e) Create an environment that fosters and rewards improvement i) Creating an infrastructure to support evidence-based practice ii) Facilitating the use of information technology iii) Aligning payment incentive iv) Preparing the workforce to better serve patients in a world of expanding knowledge and rapid change 46) Science of Human Factors Involved in Safety (USE THE PICTURE BELOW, 47, WITH THIS ON ALSO) a) Human Factor Engineering -Science of understanding how people perform under different circumstances in order to design safer systems. It takes into account: i) Capabilities and limitations ii) Interface of people, equipment, and the environment 47) Error Associated With Controlled Thinking a) Consciously solve, Error in planning "mistake", Rule or knowledge based

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48) Error Associated With Automatic Thinking (USE THE PICTURE ABOVE, 47, IN THIS ONE ALSO) a) Error in execution "slip or lapse", Skill based 49) Human Factor Engineering (week 4 slide 19 if confused by set up, also slide 24 PICTURE)

Science of understanding how people perform under different circumstances in order to design safer systems. It takes into account:  

Capabilities and limitations Interface of people, equipment, and the environment

a) Heuristics-simplify thought processes based on patterns and past experiences b) Cognitive disposition to respond i) Cognitive error, "mistake" (1) Faulty assessment of probability (2) Failure to seriously consider alternative c) Endogenous (internal) causes of error i) Related to individual versus environment, e.g. *stress, memory, fatigue, illness, language limits, hazardous attitude d) Exogenous (external)causes of error i) Related to environment, e.g. noise, heat, light, work schedule, inadequate training, poor design rules or procedures, interruptions, distractions, language barrier e) Memory limitation 7 items +/-2 50) Eleven Design Processes to commun Error a) Simplification b) Standardization c) Avoid reliance on memory d) Improve access to e) Take advantages of habits and patterns f) Exploit power of constraints g) Visual controls to shape behavior h) Team function i) Redundancy j) Decrease environmental factors 9

k) Develop systems that tolerate error and contamination 51) Hazards Involving Technology a) Two broad categories: i) Human-computer interface issues (1) Alert fatigue (2) Automation complacency (3) People place too much trust in technology and become overly reliant ii) Computer-related problems (1) Poorly designed interfaces (2) Systems designed with relevant information on different screens 52) QSEN Competencies a) Informatics b) Quality c) Patient centeredness d) Evidence based e) Teamwork f) Safety 53) QSEN Complexities of Nursing Work: a) Complexities of healthcare b) Complexities of the nursing role c) Multiple distraction d) Human Factors e) Environmental factors f) Routine diverted results in a Slip i) Capture move-routine takes over, e.g. drive to wrong place on auto-pilot ii) Description move, e.g. grab hair gel and meant to grab toothpaste iii) Associative action, e.g. go to phone when doorbell rings iv) Loss of activation, e.g. forget what you are doing when you get up g) Mistake i) Rule based-wrong rule chosen or Knowledge based-lack of or misinterpretation of data (1) Pattern matching (2) Confirmation bias (3) Overconfidence (4) Minimizing info that doesn’t fit h) Factors involved in diverted attention i) Physiologic, e.g. fatigue ii) Psychologic, e.g. emotional state iii) Environmental factors 54) Characters of Complex Adaptive System 1-Embeddedness 2-Distributed control 3-Non-linear

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4-Adaptable Elements 5-Emergence 6-Diversity 7-Order-Disorder 8-Self-organization 55) Chasing Zero: Winning the War on Healthcare a) Leadership b) Safe practices c) Technology

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