Safety in Nursing Flashcards

1
Q

What is patient safety?*

A

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

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2
Q

Describe what an incident is in healthcare*

A

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

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3
Q

Define harm in patient safety*

A

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

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4
Q

What are the four types of incidents?

A
  1. harmful incident
  2. near miss
  3. no-harm incident
  4. critical incident
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5
Q

What are the three conceptual models for patient safety?*

A
  1. Swiss cheese model
  2. Domino model
  3. Iceberg model
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6
Q

Describe the Swiss cheese model and how to prevent harm through this model*

A
  • 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
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7
Q

Describe the domino model and how to prevent harm through this model*

A
  • 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
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8
Q

Describe the iceberg model and how to prevent harm through this model*

A
  • 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
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9
Q

What are contributing factors? Do conceptual models aid or hinder in identifying them?*

A

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

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10
Q

What is a system failure?*

A

Faulty organizational process, operation, or structure that places the patient and/or HCP in danger of harm

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11
Q

What two dimensions shape organizational culture?*

A
  1. The organizational framework
  2. The behaviours demonstrated by the employees of the organization
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12
Q

Describe how an organizational framework enhances a culture of safety*

A
  • Funding for safety mechanisms (equipment, processes)
  • Organizational leaders must make safety a priority
  • Empower staff to engage in safety projects
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13
Q

Describe how the behaviour employees enhances a culture of safety*

A
  • Everyone must be on board
  • Thinking about safety at all times
  • Follow policy and procedure at all times
  • Avoid shortcuts
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14
Q

Describe reporting culture*

A

Reporting is the norm - must trust that reporting will not result in punishment

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15
Q

Describe informed culture*

A

Gains knowledge from analyzing adverse event reports - is the outcome of a reporting culture

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16
Q

What type of safety culture is the outcome of a reporting culture?*

A

Informed culture

17
Q

Describe flexible culture*

A

Open to changing processes based on new knowledge gained - requires teamwork and shared accountability, shared power, and open communication

18
Q

Describe learning culture*

A

Learns from experience, makes necessary adjustments to the system - requires the culture to be informed and flexible

19
Q

How does risk management enhance safety culture?*

A

It minimizes the occurrence of untoward events by planning for their occurrence and placing safeguards to offset the danger

Often takes the form of policies, procedures, and processes

20
Q

How does quality improvement enhance safety culture?*

A

Includes activities to enhance the patient’s (and/or staff’s) experience, outcomes, and safety

21
Q

What is an adverse event?*

A

Results in harm to the patient

22
Q

What is a critical incident?*

A

Results in significant impairment or loss of life

23
Q

What is a near miss?*

A

An event caught right before it reached the patient

24
Q

How can inter-professional communication hinder safety culture?*

A

Power/authority gradients within healthcare can serve as barriers to effective communication (i.e., Staff nurse ignores student nurse concerns about the patient)