Nursing Practice/TeamSTEPPS Flashcards
(42 cards)
Communication
A technique for communicating critical information that requires immediate attention and action concerning a patient’s condition.
- written or verbal
SBAR mnemonic
situation
background
assessment
recommendation
SBAR is a
- written or verbal
purpose provide essential, concise information usually during critical situations
Situation
focus on the seriousness of the situation with the exact circumstances explained
Name, Unit, Pt Name, and Room Number
Background
essential info related to only to current situation
age and gender
admitted date and for
presented with
Hx
Assessment
precise statement of data related to the situation, VS and findings
qualified staff
significant labs
clinical concerns
Recommendation
resolving issue based on findings
orders, meds, radiology, lab, therapies, consult, evaluate pt
How to receive a verbal order?
Sender initiates the message
Receiver accepts message and provide feedback
sender reads back order to ensure correct message received
Write Dr’s, NP’s, and RN’s name
Team Goal of Quality Improvement
DESIRED PT OUTCOMES (MAXIMIZE QUALITY OF CARE)
Sentinal event
state reportable incident and includes investigation into hospital neglect
a broken bone or worse
Define “Team”
people working together for a common goal
If a medication is prescribed for pain and you know that it also lowers fever, can you give that medication for fever even though it says PRN for pain?
No, not prescribed for that
Leadership is who
Is anyone seen as a leader because we are all advocating for the pts
Team Stepps Triangle
The center is Pt care team with these skills
-leadership
-situation monitoring
-mutual support
-communication
The 3 corners with arrows in and out are
Knowledge
Attitudes (trust and team orient)
Performance (adapt, accurate, productive, efficiency, and safety
TeamSTEPPS has what 5 key principles?
team structure
communication
leadership
sitaution monitoring
mutual support
Model for Improvement PDSA
Plan - idea for action
Do - make a change
Study - test and collect data
Act - adjust based on results
National Pt Safety Goals 2022
ID Pt correctly
Improve staff communication
Use med safety
Alarms safely
Prevent infections
Id pt safety risk
Improve equity
Multi-Team System for Patient Care Triangle (tip to base)
Pt and family
Core team and Contigency
Coordinating team and ancillary and support
Administration
Magnet
Designation that empowers nurses through shared governance to provide the best nursing care and outcomes
Measures the strength and quality of Nursing
Empowerment
Shared decision-making
Accountability
Magnet Culture
Visionary nursing leadership
Strong nursing representation at the top levels of management
Building an environment that encourages participation
Empowering nurses in patient care
Showing superior patient outcomes
Magnet Culture of Excellence
great leaders
great structures
great nurses
knowledge and innovation
great outcomes
Health Info Technology
Computers, mobile devices, and Telehealth (global help)
Medication administration applications
Computerized provider order entry
Protected health Information (PHI) – document accurate in EHR
Electronic health record (EHR) – direct access to pts chart, decrease Med ERRORS, decreased duplicate orders, decrease errors in handwritten orders
Protect confidentiality of patient’s protected health information
Document appropriately in electronic health records
Use communication technologies to coordinate patient care
Respond correctly to clinical decision-making alerts – LAB VALUES AND CORRECTION
HIPPA
includes your own medical record or friends/family medical records
Tier 1-4 = $100-50000 per violation
What does professional nursing look like to you?
Communication
Punctual
Integrity
Accountable
Team player
Compassionate
Honest
Accurate charting
Bad is the opposite of them