Medical Errors & QSEN Safety Competencies

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Questions and Answers

What is defined as the third leading cause of death in the USA?

Cancer

Heart disease

Accidents

Medical errors (correct)

Which of the following is NOT one of the TJC 2024 National Patient Safety Goals for hospitals?

Identify patients correctly

Prevent mistakes in surgery

Increase patient waiting times (correct)

Improve staff communications

What is one of the recommended practices for infection control?

Using less disinfectant

Skipping equipment sterilization

Hand hygiene (correct)

Increasing visitor access

Which QSEN competency focuses on minimizing harm through systemic effectiveness?

Safety Signup and view all the answers

What should be included in emergency preparedness to avoid failures in safety?

Course-specific preparation Signup and view all the answers

Which practice is included under medication safety protocols?

Medication reconciliation Signup and view all the answers

What does failure to rescue refer to in healthcare?

Failing to identify complications early Signup and view all the answers

Which QSEN competency emphasizes the importance of teamwork in care?

Teamwork & Collaboration Signup and view all the answers

What is the primary goal of activating the fire code in a healthcare setting?

To alert the appropriate emergency personnel Signup and view all the answers

Which type of medication error involves prescribing a medication that is not necessary?

Commission error Signup and view all the answers

What annual financial impact do medication errors have on U.S. hospitals?

$40 billion Signup and view all the answers

Which of the following was identified as the most common nursing student medication error?

Wrong dose Signup and view all the answers

What is the recommended way to overcome barriers to medication safety in nursing?

Accept corrective feedback Signup and view all the answers

In the context of emergency preparedness, which action should follow the activation of the fire code?

Confine the fire by closing doors and windows Signup and view all the answers

Which type of medication error occurs when a drug is not taken by the patient?

Omission error Signup and view all the answers

What does a 'near miss' in a healthcare context refer to?

A potential error that did not harm the patient Signup and view all the answers

What demographic factor significantly increases fall risk among older adults?

Being over 65 years old Signup and view all the answers

Which of the following is considered a risk factor for falls?

Cognitive impairment Signup and view all the answers

Which fall prevention intervention involves keeping essential items accessible to the patient?

Call light within reach Signup and view all the answers

What was the reduction in overall inpatient falls observed in the study of a patient-centered fall-prevention tool kit?

15% Signup and view all the answers

How much does the annual cost of falls amount to?

$31 Billion Signup and view all the answers

Which of these interventions is recommended to enhance fall prevention measures?

Offering assistance to the toilet every 2 hours Signup and view all the answers

What percentage reduction in fall injuries was reported from the implementation of the fall-prevention tool kit?

34% Signup and view all the answers

Which of the following factors does NOT contribute to fall risk?

Healthy lifestyle choices Signup and view all the answers

Study Notes

Medical Errors & Safety

Medical errors annually result in between 210,000 - 440,000 patient deaths and are the third leading cause of death in the USA.
Cost of $20 Billion dollars/year in the US.
Healthcare failures contributing to safety lapses include failure to recognize, failure to rescue, and failure to plan.

QSEN Competencies

The QSEN competencies include:
- Patient-Centered Care
- Teamwork & Collaboration
- Evidence Based Practice
- Quality Improvement
- Safety
- Informatics

QSEN defines Safety as:

Minimizing risk of harm to patients and providers through both system effectiveness and individual performance.

TJC 2024 National Patient Safety Goals for Hospitals

Identify patients correctly
Improve staff communications
Use medications safely
- Label Medications
- Medication Reconciliation
Use alarms safely
Prevent Infection
- Hand hygiene
Identify Patient Safety Risks
Prevent Mistakes in Surgery

Fire Safety - RACE

Rescue anyone in immediate danger.
Activate the fire code and notify appropriate person.
Confine the fire by closing doors and windows.
Evacuate patients and other people to a safe area.

The BIG 3 in Safety Errors: Medication Errors

Medication errors are the most common safety errors.
Medication errors occur at any point in the medication use process.
1.2 million patients are harmed each year by medical errors made in US hospitals.
Over $40 Billion annually goes toward treating the consequences of medication errors.
Computerized medication ordering systems can prevent 84% of dose, frequency, and route errors.

Types of Medication Errors

Omission: Drug not prescribed, dispensed, or administered.
Commission:
- Wrong drug, dose, or route
- Wrong patient
- Frequency, timing, or duration of the drug is incorrect
- Allergic reaction
- Drug interaction

Nursing Student Medication Errors

A systematic review of 1904 nursing student medication errors found:
- Majority of errors were wrong dose (17%).
- Other common errors: Omission (16%), Wrong time (13%).

Student Barriers to Building a Safer Culture

Lack of acceptance of corrective feedback.
Near misses (no harm to patient) often lack learning opportunities.

The BIG 3 in Safety Errors: Falls

Falls are considered a "never event" in healthcare.

Fall Demographics

Females are more likely to fall than males.
Fall risk increases with age, especially over age 65.
Over 2.8 million older people are treated in the ED for fall injuries each year.
800,000 patients a year are hospitalized after falls.
Falls result in 27,000 deaths annually.
Those over 75 years of age who fall are 4-5 times more likely to be admitted to an ECF.
50% of people over 75 years old who fall will die within 1 year.
Cost of falls: $31 Billion Annually.

Falls Risk Factors

65 years old or older
History of falls
Cognitive impairment
Altered gait
Medications
Incontinence
Unsafe environment
Sensory deficits
Orthostatic hypotension
Depression
Assistive devices
Confusion or disorientation
New environment

Fall Prevention Interventions

Complete fall assessments
Frequent rounding
Place on fall precautions
Offer assistance to the toilet Q2
Treaded socks
Bed in low position and bed alarms ON
Personal items within reach
Call light within reach/Answer call lights promptly

Evaluation of a Patient-Centered Fall-Prevention Tool Kit

A nonrandomized controlled trial of a patient-specific fall-prevention tool kit was associated with:
- 15% reduction in overall inpatient falls.
- 34% reduction in fall injuries.

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Description

Explore the critical concepts surrounding medical errors and patient safety, including the QSEN competencies aimed at improving healthcare delivery. Learn about the leading causes of patient harm and the National Patient Safety Goals that guide hospitals in enhancing safety measures. This quiz will test your knowledge on best practices in patient-centered care and safety protocols.