Chapter 10  Safety Concerns in Healthcare

1. Chapter 10Safety Concerns in Healthcare

2. Question • Is the following statement is true or false? A 1999 study conducted by the Institute of Medicine found that between 44,000 and 98,000 American died each year from preventable error in hospitals alone.

3. Answer • True • Rationale: A 1999 study conducted by the Institute of Medicine found that between 44,000 and 98,000 American died each year from preventable error in hospitals alone. This spurred the agency for healthcare research and quality and the Joint Commission that grants accreditation status to hospitals to take action.

4. National Organizations and Actions • The Institute of Medicine study • The National Quality Forum • Serious reportable events • Safe practice

5. Question • Is the following statement true or false? Sentinel event is specifically a loss of limb or function.

6. Answer • False • Rationale: Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.

7. National Organizations and Actions (cont.) • The Joint Commission • Sentinel event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof • Serious injury specifically includes loss of limb or function • The risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome • National Patient Safety Goals

8. Serious Adverse Events or Outcomes • Instances of error that have the potential for serious harm or death to the client. • Include occurrences • Surgery on the wrong body part • A maternal death • Tubing and catheter misconnection • Overdose with commonly used anticoagulants • Discharge of infant to the wrong family • Joint Commission refers to as sentinel events.

9. Question • Is the following statement true or false? In 2003, with the help of AHRQ, the National Quality Forum identified 20 safe practices which were defined as practices that reduce the risk of harm from the processes, systems, or environments of healthcare.

10. Answer • False • Rationale: In 2003, with the help of AHRQ, the National Quality Forum identified 30 safe practices which were defined as practices that reduce the risk of harm from the processes, systems, or environments of healthcare.

11. National Organizations and Actions • Centers for Medicare and Medicaid services • Federal safety legislation

12. Addressing Safety Concerns • Organizational culture • Culture of safety • Root cause analysis • Matching needs with delivery capability

13. Addressing Safety Concerns (cont.) • Communications • Patient safety during hand off • Briefing using SBAR technique • Tools to improve communication • Team STEPPS • Call out • Check back

14. Question • Is the following statement true or false? The universal protocol includes preprocedure verification process, marking the surgical site, and performing a "time-out" before each surgery when all members of the team review a check list developed to prevent surgical errors from happening.

15. Answer • True • Rationale: The universal protocol includes preprocedure verification process, marking the surgical site, and performing a "time-out" before each surgery when all members of the team review a check list developed to prevent surgical errors from happening.

16. Addressing Safety Concerns (cont.) • Adopting safe practices in specific clinical care settings • Universal protocol: preprocedure verification process, marking the surgical site • Time-out: before each surgery when all members of the team review a check list developed to prevent surgical errors from happening

17. Addressing Safety Concerns (cont.) • Infection control • Failure to rescue and nurses time at the bedside • Nurse staffing • Preventing falls

18. Question • Is the following statement true or false? Failure to rescue is increased when there is more nursing time spent at the patient's bedside.

19. Answer • False • Rationale: Failure to rescue is decreased when there is more nursing time spent at the patient's bedside.

20. Addressing Safety Concerns (cont.) • Increasing safe medication administration • Eliminating ambiguous abbreviations

21. Addressing Safety Concerns (cont.) • Computerized physician/provider order entry • Computerized decision support systems • Computerized adverse drug monitoring • Barcode point of care • Smart pumps • Nurse’s role in medication safety

22. Addressing Safety Concerns (cont.) • Additional responsibilities of the nurse for safety • Nurses have devised methods to reduce errors. • Work-around jeopardize patient safety by eliminating steps in a process or creating ways to manage outside of the system. • Nurses constitute the largest proportion of healthcare workers, their role in the prevention of errors is critical.