NURS103 Study Guide - Final Guide: Swiss Cheese Model, New Zealand Studies, Systems Engineering

49 views5 pages
25 Aug 2016
Department
Course
Professor
Patient Safety
*Right of the patient and their family to know when a medical mistake was made
*Accountability
*Advocate for patient rights
Silo thinking= a team that is pretty focused on their own area but not able to step back and look at the broader picture
(departments not talking to each other)
Adverse event= an unintended injury or complication that results in disability at the time of discharge, death or pro-longed
hospital stay and that is caused by health care management rather than by the patient’s underlying disease process
A safe healthcare practitioner:
Understands the healthcare system – supports/barriers to safe patient care (scope of practices and policies in the institution->
chain of communication)
Anticipates problems in the System (prevention)
Vigilant for things that “aren’t right” (practical wisdom)
Team player and confident in own knowledge (deep knowledge base
Experience in dealing with situations (novice to expert clinical experience)
Has an understanding of the complexities of the system that they work in
Has a deep knowledge base of anatomy physiology, pathophysiology, and pharmacology
Must have skills and knowledge of how to safely perform procedures
Must understand how to be a team player – how to be humble and confident even when abilities are questioned
Must have experience so that patterns can be recognized and common situations are handled in an expert manner
Must have practical wisdom – which means knowing what ought to be done and what is good for the patient
Must have the ability to work in chaotic situations
Have emotional intelligence (which will be talked about later)
Remember to be consistent especially w/ meds!
oClarify and make sure you fully understand and always double check!
oAsk the patient as well-> patient have the right to know what they're taking so listen to your patients!
*INVOLVE YOUR FUCKING PATIENTS IN THE CARE PLAN-> ASSESS ALL PARTS OF LIFE SO IT’S THE BEST FOR THEM, PLUS THEY
KNOW WHAT THE FUCK THEY NEED
Patient Saftey
A discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of
health care delivery
Attributes of health care systems
oMinimize the incidence and impact of adverse events
oMaximize recovery from adverse events
Goal is to minimize the number and severity of adverse events
Adverse event/harmful incident-> results in unintended harm to a patient.
oThe resulting harm is due to the care or services provided to a patient and is not related to the underlying medical condition.
oAn adverse event may be either preventable or unpreventable.
The goal of patient safety groups is to minimize incident and maximize recovery from adverse events
Patient safety advocates aim to…
oEliminate preventable harm
oRedesign systems for high reliability
oRecognize human factors-> communication breakdown
oDevelop a culture change-> so people will actually come up and report
Reduce individual blame
Be open about failure
oIt has been recognized and acknowledged that hospitals are not safe –> hospitals all over the world
oThe goal of the patient safety movement is to adopt a fairly universal approach to improving the care in hospitals. The
goals listed in this slide are clear and simple.
oPut simply, patient safety experts want to shift the culture within hospital systems –> systems that formerly laid the
blame on individual healthcare personnel but didn’t consider contextual factors within hospitals.
Worldwide recognition that patient safety is a problem
USA:1999 – Institute of Medicine – To Err is Human
oJoint Commission on Accreditation of Healthcare Organizations (JCAHO)
Australia & New Zealand: early 1990’s: moves to improve quality in healthcare
United Kingdom: National Health Service (NHS) – targets patient safety issues
find more resources at oneclass.com
find more resources at oneclass.com
Unlock document

This preview shows pages 1-2 of the document.
Unlock all 5 pages and 3 million more documents.

Already have an account? Log in
In 1999 - Institute of Medicine report in the USA called To Err is Human that identified healthcare mistakes as a public health issue
this report claimed 44 000 deaths & maybe even 98 0000 deaths could be attributed to health care errors EACH YEAR
Australia & New Zealand – studies revealed similar shocking statistics about adverse events (or errors) &
UK – in June 2000 the National Health Service published An organization with a memory which identified the impact of adverse
events on patient health. In the UK some studies claim that up to 10 000 persons a year experience an adverse event related to
drugs – many of these are seen as preventable.
Sadly, adverse events in many countries are linked to patient death and to drains on the health care system - when mistakes end up
costing the system more.
WHO 10 facts
oPatient safety issues are worldwide
o1/10 patients harmed in care
oRisk of infection 20% higher in developing countries
o1.4 million people – hospital acquired infections
o50% hospital equipment worldwide is faulty
oSome countries-70% needles unsterilized/re-used
oSurgeries-1/2 of all adverse events
oMistakes cost millions to HC systems worldwide
oPt experiences are driving reform to HC systems
Patient safety in Canada: Canadian Patient Safety Initiatives
Research ALERT - studies completed (notably Baker, G. Ross & Norton, P. & colleagues)
Meetings & “think tanks” -> Government, Stakeholders, Senior Leaders
oFocus on Systems perspectives of Patient Safety
oGovernment agencies formed i.e. Canadian Patient Safety Institute (CPSI); Institute for Safe Medication Practices
(ISMP); Health Quality Council of Alberta (HQCA)
In 2004, Dr. Ross Baker and colleagues published the Canadian Adverse Events Study
This group focused on Adverse events within Canadian hospitals.
Again...an adverse event is any event that results in “unintended injuries or complications that are caused by health care
management – rather than by the patient’s underlying disease and that led to death, disability at the time of discharge or
prolonged hospital stays”.
One purpose of the study was to identify adverse events and to whether or not the adverse events were preventable.
of 255 charts revealed adverse events and of those 21% resulted in patient death.
Also 36.9% were found to be preventable. Of those who didn’t die – 1 521 additional hospital days were associated with adverse
events.
The group concluded that of the almost 2.5 million annual admissions to hospitals – 185 000 are associated with Adverse Events
and close to 70 000 of those are potentially preventable.
ISNP-> under eclass
Safer systems now!
oSafety as a Priority
Magnitude of the problem
Specific Challenges to Patient Safety
oCanadian Patient Safety Institute/ Safer Systems Now/Patients for Patient Safety Now
Online sources made Key Recommendations
oToday’s Focus: Safety Domain #3
oCommunication
oThe government had many Meetings & “think tanks” – and studies and Government, Stakeholders, Senior Leaders put a
focus onto patient safety.
oIt was agreed that the focus needed to be on health systems and the many improvements needed within systems.
oTo meet this goal…Important Government agencies formed i.e. Canadian Patient Safety Institute (cpsi); Institute for
Safe Medication Practices (ismp); Health Quality Council of Alberta (HQCA)
CPSI safety competencies
oCommitment to a Culture of Patient Safety
oFocus on effective teamwork for Patient Safety
oEffective communication for Patient Safety
oManagement of Safety Risks
oOptimize Human and Environmental Factors
oRecognize, Respond and Disclose Adverse Events
oKey Safety Competencies (needed for making the health care systems across the country safer) were developed.
find more resources at oneclass.com
find more resources at oneclass.com
Unlock document

This preview shows pages 1-2 of the document.
Unlock all 5 pages and 3 million more documents.

Already have an account? Log in

Get access

Grade+
$10 USD/m
Billed $120 USD annually
Homework Help
Class Notes
Textbook Notes
40 Verified Answers
Study Guides
1 Booster Class