Safety in Nursing Flashcards
What is patient safety?*
The reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes
Describe what an incident is in healthcare*
Events, processes, practices, or outcomes that are noteworthy by virtue of the hazards they create or the harms they cause to patients - event or circumstance that could have resulted, or did result, in unnecessary harm to a patient
Define harm in patient safety*
A product of unsafe acts or safety events and can impact any dimension of health
It occurs as a result of health care interaction, whether or not it is related to the reason the person entered the healthcare system
What are the four types of incidents?
- harmful incident
- near miss
- no-harm incident
- critical incident
What are the three conceptual models for patient safety?*
- Swiss cheese model
- Domino model
- Iceberg model
Describe the Swiss cheese model and how to prevent harm through this model*
- A harmful event passes through several layers to reach the patient
- Have to find the holes in each layer it passed through and find ways to prevent them
- Prevention at even one layer would stop the event
Describe the domino model and how to prevent harm through this model*
- Event passes through multiple layers/dominoes, but as it passes through, it creates more momentum (more falling dominoes)
- Have to find ways to stop the momentum
- Only have to stop the domino at one layer from falling to stop the event
Describe the iceberg model and how to prevent harm through this model*
- The incident is only the tip of the iceberg that we can see
- Have to look at all the submerged (invisible) aspects that led to the event
- Correction/prevention often occurs at the invisible level
What are contributing factors? Do conceptual models aid or hinder in identifying them?*
They are the reasons, situations, factors, or latent conditions that played a role in the genesis of an adverse event
Models help identify contributing factors
What is a system failure?*
Faulty organizational process, operation, or structure that places the patient and/or HCP in danger of harm
What two dimensions shape organizational culture?*
- The organizational framework
- The behaviours demonstrated by the employees of the organization
Describe how an organizational framework enhances a culture of safety*
- Funding for safety mechanisms (equipment, processes)
- Organizational leaders must make safety a priority
- Empower staff to engage in safety projects
Describe how the behaviour employees enhances a culture of safety*
- Everyone must be on board
- Thinking about safety at all times
- Follow policy and procedure at all times
- Avoid shortcuts
Describe reporting culture*
Reporting is the norm - must trust that reporting will not result in punishment
Describe informed culture*
Gains knowledge from analyzing adverse event reports - is the outcome of a reporting culture