Chapter 26: informatics and documentation lesson assessment Flashcards
(18 cards)
Hand-off report:
-transfer and acceptance of patient related data and responsibility from one caregiver or team of caregivers to another
senders=
recievers=
-relinquishing responsibility
-assuring responsibility
Can an unlicensed assistive personal may participate in a handoff report with a nurse partner:
-YES
Who requires all healthcare providers to implement handoff, reinforcing agency for healthcare research and quality (AHRQ)
-Joint commission
When incomplete or inaccurate info. is not shared during a handoff report, patient may:
-not receive the needed. care, proper mediation, or recommended therapies
Types of handoff reports (3):
-SBAR
-IPASS
-ANTICipate
SBAR:
-nurse/HCP handoff
-situation, background, assessment, recommendation
IPAS:
-illness severity
-patient summary
-action list
-situation awareness and contingency plans
-synthesis
ANTICipate:
-Administrative data must be accurate
-New clinical info. must be
-Tasks perform by HCP must be explained
-Illness severity must be communicated
-Contingency plans for changes in clinical status must be documented
Sentinel event=
-unexpected occurrence involving death, harm, or severe harm
-signal the need for immediate investigation and response
Types of sentinel event:
-death
-suicide
-wrong site/procedure
-infant abduction
Example of reduced erros:
-education:facility wide and unit based
-surveys to determine understanding of safety practices
-benchmarks to compare effectiveness
Incident report:
-official documentation of the facts of an accident or injury related incident and/or breach of practice or policy with patient/employee/ visitor
nearmiss=
incident report of an incident that could have occured
nearmiss includes info such as:
-location
-severity
-witness
-measures taken
Risk management/quality improvement document includes (3):
-be written by the nurse that was involved with patient
-be nonjudgemental, objective, and factual
-not part of medical record
Example of incident reports:
-staff injury
-medication error
-equipment malfunction
-patient fall
Incident report helps with:
-patient safety
-safe reporting
-constructive response
-meaningful learning
