NUrsing Role And Scope Discussion DQ 13

After reading Chapter 8 and reviewing the lecture power point (located in lectures tab), please answer the following questions. Each question must have at least 3 paragraphs and you must use at 3 least references (APA) included in your post.

Additionally, you are expected to reply to two other students and include a reference that justifies your post. Your reply must be at least 3 paragraphs.

1. Describe a clinical experience that was troubling to you. Describe what bothered you about the experience and what could have you done differently utilizing critical thinking.

2. Describe how patients, families, individual clinicians, health care teams, and systems can contribute to promoting safety and reducing errors.

3. Describe factors that create a culture of safety.

Wishing all a great week ahead!

ORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERS

• Ensures that nursing practice is safe, effective,

efficient, equitable, timely, and patient-centered

(ANA)

• Minimization of risk of harm to patients and

providers through both system effectiveness and

individual performance (QSEN & NOF)

To Err is Human: Building a Safer

Health System (IOM, 2000)

• At least 44,000 and possibly up to 98,000

people die each year as the result of

preventable harm

• Cause of the errors is defective system

processes that either lead people to make

mistakes or fail to stop them from making a

mistake, not the recklessness of individual

providers

Error

• Error is the failure of a planned action to be

completed as intended, or the use of a wrong

plan to achieve an aim with the goal of

preventing, recognizing, and mitigating harm

• Common errors include drug events and

improper transfusions, surgical injuries and

wrong-site surgeries, suicides, restraint-related

injuries or death, falls, burns, pressure ulcers,

and mistaken patient identities (IOM, 2000)

Event Analysis

• Individual approach or system approach

– Culture of blame

– Culture of safety

– Just culture

• Root-cause analysis

• TERCAP

• Reason’s Adverse Event Trajectory NUrsing Role And Scope Discussion DQ 13

Classification of Error

• Type of error

– Communication

– Patient management

– Clinical performance

• Where the error occurs

– Latent failure and active failure

– Organizational system failures and system process

or technical failure

Human Factor Errors

• Skill-based

– Deviation in the pattern of a routine activity such

as an interruption

• Knowledge-based

• Rule-based

– Conscious decision by the nurse to “workaround”

or take a shortcut, so the system defense

mechanisms are bypassed, thereby increasing risk

of harm to patient

To Err is Human: Building A Safer

Health System (IOM, 2000) (1 of 2)

• User-centered designs with functions that make

it hard or impossible to do the wrong thing

• Avoidance of reliance on memory by

standardizing and simplifying procedures

• Attending to work safety by addressing work

hours, workloads, and staffing ratios

• Avoidance of reliance on vigilance by using

alarms and checklists

To Err is Human: Building A Safer

Health System (IOM, 2000) (2 of 2)

• Training programs for interprofessional teams

• Involving patients in their care; anticipation of

the unexpected during organizational changes

• Design for recovery from errors

• Improvement of access to accurate, timely

information such as the use of decision-making

tools at the point of care

Crossing the Quality Chasm: A New

Health System for the 21st Century

(IOM, 2000)

• STEEEP

– Safe

– Timely

– Effective

– Efficient

– Equitable

– Patient-centered

• 10 rules for redesign

– Rule #6: Safety is a

system property

Keeping Patients Safe: Transforming the

Work Environment of Nurses

(IOM, 2004) • Chief nursing executive should have leadership role

in the organization

• Creation of satisfying work environments for nurses

• Evidence-based nurse staffing and scheduling to

control fatigue

• Giving nurses a voice in patient care delivery

• Designing work environments and cultures that

promote patient safety

Preventing Medication Errors: Quality

Chasm Series (IOM, 2006)

• Paradigm shift in the patient-provider

relationship

• Using information technology to reduce

medication errors

• Improving medication labeling and packaging

• Policy changes to encourage the adoption of

practices that will reduce medication errors

Joint Commission National

Patient Safety Goals

• Reviewed and updated annually, focuses on

system-wide solutions to problems

• 2015 goals: Identify patients correctly, use

medications safely, improve staff

communication, use alarms safely, prevent

infection, identify patient safety risks, and

prevent mistakes in surgery

National Quality Forum Goals

• Improve quality health care by setting

national goals for performance improvement

• Endorsement of national consensus standards

for measuring and public reporting on

performance

• Promoting the attainment of national goals

National Quality Forum Safe Practices

• Endorsed safe practices defined to be

universally applied in all clinical settings in

order to reduce the risk of error and harm for

patients NUrsing Role And Scope Discussion DQ 13