4.1 Creating a Culture of Safety

Question 1

Reportable Errors

Answer 1

• Sentinel Events
• Adverse events causing harm
• Unanticipated outcomes (serious injury/death)

Question 2

Common Types of Errors

Answer 2

• Medication administration
• Technical failures
• Wrong surgery sites
• Transfusion errors
• Inaccurate diagnoses
• Inadequate communication
• Equipment failures
• Incorrect labeling of lab specimens

Question 3

Root Cause of Errors

Answer 3

• Most common is communication

Other causes
- Inadequate information flow from one unit to another causing poor care coordination
- Policies/procedures that are not followed appropriately or lack of documentation
- Incomplete patient assessments, lack of consent, or insufficient patient education
- Inadequate education for new workers
- Inadequate staffing and working on unfamiliar units
- Inadequate policies

Question 4

Framework for Quality Care

Answer 4

• Safe (avoid harming the patient)
• Effective (provide services that will benefit the patient based on EBP)
• Patient Centered (respectful to patient preferences, needs and values)
• Timely (Reduce wait times and harmful delays for patients and caregivers)
• Efficient (Avoid waste of equipment, supplies, and energy)
• Equitable (provide high quality care for everyone)

Question 5

Joint Commission Safety Goals

Answer 5

• Identify patients correctly
• Improve staff communication
• Use medicine safely
• Use alarms safely
• Prevent infection
• Identify patient safety risks
• Prevent mistakes in surgery

Question 6

QSEN (Quality Safety Education for Nurses)

Answer 6

• Patient centered care
• Teamwork and collaboration
• EBP
• Quality improvement
• Safety
• Informatics