Safety & Quality Flashcards
What is quality care?
Good care.
What does TJC stand for?
The Joint Commission (regulatory agency)-They have national patient safety goals.
What does safety mean?
Freedom from accidental injury & also fundamental. You keep them safe!
What type of hazard is a fall?
Falls are one of the biggest safety hazards in the hospital
What is are operational systems?
Ex. Anderson Hospital has policies & procedures in place & tracking-keeps people responsible for their actions
What is System Processing?
Trying to minimize incidence of errors to keep pt. safe for ex. certain arm bands for kidnapping of infants & it beeps when close to door. Also want to avoid injuries to patients while caring for them & follow the rules.
How does EHR keep patients safe?
Before giving medications, the mar may alert you to go look at labs results to be sure you are not giving to much of the medication before you try to give another dose.
Areas of safety concerns in the hospital?
*Surgical -Not being sterile or not having the right pt./Not doing right thing ( Removing wrong body part), Leaving instruments/sponges in pt. Gases can be flammable or Cautery when using it.
-Feelings getting in the way of dealing with pt. care-these are distractions & not being able to get things done
-Food safety, administration dosages & not charting medications, treatment, & diagnoses properly., side rails
-Be knowledgeable of precautions & ordered appropriately & following directions
-High fall risk (sign outside door)/leave door open/HIPPA Violation if chart open & safety concern because someone can easily chart
-Toileting/side rails down, malfunctioning equipment-tagged by biomed until fixed
-Aggressive pt. (sundowning)
What is the scope of practice for safety & quality?
To go from no error to death-Trying to keep all patients safe from injury. There are different types of errors listed below.
What is an adverse event?
Results in unattended harm (Med errors (#1 error), allergic/anaphylactic response, Falls, Burn (heating pads), & Infection
What is a near miss?
(3 levels of errors that almost happened but you caught the error)-Medication related (seen most-hydroxyzine/Hydroline), & wrong dosage-Need to report/learn from it & separate the drugs(improve processes)
What are sentinel events or a Nevel event?
Should never happen-Reported national to Joint Commission that can result in some serious or death-Like Medication errors (giving potassium to fast through IV)
*Surgery-wrong limb taken off or surgical instrument left in pt.
*Drop baby or Infant abduction or something to cause the baby to die & fall result in serious injury or death
*Mismatched blood (infected blood)
*Losing a pt. (like a suicide pt). at risk
*Severe pressure ulcer injury or CAUTI
What is a root cause analysis?
What really happened? (Was there not enough staff or wrong procedures)
What are some types of errors?
*Diagnostic-Any error involving some type of testing (mislabeling specimen, follow up with test (High level of electrolyte balance like 6 of Potassium)
*Treatment Error-Delay of treatment (Nurse didn’t do her job)
*Preventative Error-Failure to provide prophylactically care (Access pt. for blood clots) could lead to sentinel event
*Communication Failure-Lack of good communication/Can lead to adverse event/sentinel event
Patient Transfer/Handoff report to another unit/Beside Reports are bad with communication.
What are the placement of errors (What caused the error)?
*Active or Sharp Errors-(Pertaining to one person) Provider or nurse
*Latent (dull) Error-Flaw in the system (flaw in how call schedule with providers (wrong provider called) or the way medications are given
*Always access pt. first if an error is made. Then if problem with amount(twice dosage) of BP Medication-check another BP, Contact provider, Watch BP, Let charge nurse/supervisor, & chart. Take any orders given & do incident report in timely manner.
*Incident Report-Documentation of errors sent to error department/Very detailed of what happened (TIME,DATE, PT. & WHAT HAPPENED) & not part of Electronic Record but with facts in Electronic Record)
-Goal to change processes and look for opportunities to do better