Patient Safety and Quality Care

Improving Safety and Quality Care

• High-quality nursing leads to better patient outcomes.
• Patient safety is a global and national concern.
• 44% of harmful events are preventable.

Role of the Nurse

• Positively impacts both patient safety and quality of care.
• Nurses are ethically obligated to promote safety and quality.
• Integral to ensuring patient safety in all care aspects.
• The ANA Code of Ethics has an imperative statement about safety.
• Key position to impact patient safety and quality care, with a moral obligation to promote them.

Medical Errors Defined

• Failure to complete a planned action as intended, or using the wrong plan to achieve an aim.
• Adverse events are patient safety incidents caused by medical management.
• Errors of omission mean action is not taken.
• Errors of commission mean wrong action is taken.

Unsafe Acts

• Error occurs where a potential hazard exists.
• Some errors result from violations, which are deliberate deviations from safe practice.

Types of Medical Errors

• Slips are execution errors that don't result in the intended outcome and are observed by others.
• Lapses are execution errors with memory failure, observable only to the nurse.
• Mistakes involve wrong decisions or actions due to incorrect knowledge or judgment.
• Near misses are potential errors discovered before they are carried out.
• Adverse events/patient safety events happen when a patient is injured by medical management.
• Sentinel events, such as death or permanent harm, require intervention to sustain life and must be reported.

Causes of Medical Errors, Approaches

• Can be attributed to human factors or system errors, unintentional

Human Factors Contributing to Medical Errors

• Includes staffing levels and shortages.
• Includes staff education and competencies.

Communication Factors

• Includes patient and family communication.
• Includes intraprofessional & interprofessional communication.

Leadership Factors

• Includes organizational structure.
• Includes policies and procedures.
• Includes practice guidelines.

How to Avoid Medical Errors

• Establish a culture of safety.
• Standardize processes via a systems approach.
• Initiate initiatives to improve safety.
• Use appropriate data analysis tools.
• Collect data on errors and incidents to identify improvement opportunities and track progress.

Incident Reporting

• Needed for incidents, events, or unusual occurrences.
• It's often self-reported and required by regulatory bodies.
• This includes patient falls, employee injuries, visitor injuries, and medical errors.
• Reporting is done by the person who observed the incident or first arrived on the scene.
• The priority is to ensure the patient is safe.
• Only facts should be documented.
• Do not include that an incident report was completed in the patient's medical chart. These reports are often completed on a computer system and should help maintain a culture of safety.

Examples of Errors

• A nurse misinterprets a patient’s symptoms and administers the wrong medication because they believed the patient was experiencing anxiety, but it was a cardiac issue.
• A nurse prepares to administer the wrong medication but realizes the error after double-checking the patient’s medication and MAR and does not give the medication.
• A nurse forgets to document a medication administration or fails to give a scheduled dose of medication.
• A nurse intends to give a patient an oral medication but accidentally administers it via IV because they reached for the wrong syringe and another nurse witnesses the error.

Classifying Errors

• Examples include mistakes, near misses, lapses and slips.

Culture of Safety Details

• Provides a blame-free environment and supports nurses.
• Encompasses 3 stages: safety management is based on rules and regulations, safety is an organizational goal, and safety performance is dynamic and continuously improving.
• Focus on regulatory bodies and compliance.
• Safety should be addressed as organizational goals
• Safety is everyone's responsibility, emphasizing communication, training, and management analysis, focusing on what/how, not who.

Just Culture

• Is fair to those who make an error.
• Encourages nurses to learn from one another.
• Nurses should report all errors without fear.
• Focuses on responsibility with constructive feedback.
• Is a part of a safety culture
• Staff members can voice concerns when there is a safety risk through CUS which includes; being concerned, being uncomfortable and determining if it is a safety issue.

Standardization

• Important for identifying potential ways something can be used and reasons for its use.

Patient Safety Initiatives

• Agencies: AHRQ, ANA, NQF.

AHRQ

• Agency for Healthcare Research and Quality is a foundation for understanding patient safety using a systems approach.
• The Patient Safety Network (PSNet) website is a resource for safety information.
• Provides leaders with tips to prevent medical errors and measure healthcare quality.

ANA

• American Nurses Association handles patient safety and quality initiatives.
• The National Database of Nursing Quality Indicators (NDNQI) reflects elements of patient care affected by nursing quality and quantity.
• Includes structure indicators (staffing), process indicators (hand hygiene), and outcome indicators (pressure ulcer rates).

National Quality Forum (NQF)

• Responds to the Advisory Commission, Consumer Protection, and Quality in the Health Care Industry Act.
• Intends to help Americans have more affordable healthcare and improve their health.
• Focuses on reducing hospital admissions, healthcare-associated conditions, and harm from inappropriate care.

IHI (Institute for Healthcare Improvement)

• Founded in the late 1980s improve healthcare by removing roadblocks and introducing innovations.
• Has initiatives like the 100,000 Lives Campaign which reduces morbidity and mortality in the U.S. health-care system
• The 5 Million Lives Campaign reduces illness or medical harm.

IHI Initiatives

• Rapid Response Teams, MI Protocols, medication reconciliation, central line bundles (CLABSI), surgical site infection prevention, and acquired pneumonia prevention.
• Focus on preventing catheter-associated UTIs (CAUTI), sepsis, ulcers, MRSA, surgical site infections, and CHF.
• Utilizes assistance from board members to assist in care improvements.

The Joint Commission

• Accredits and certifies health-care organizations and reviews agency activities related to sentinel events.
• Supports informed patients through the Speak Up programs
• Has national patient safety goals developed in 2002

WHO (World Health Organization)

• Committed to patient safety since 2002, addresses it as a global health issue
• Through the Patient Safety Program & High 5’s Project, aimed to reduce 5 safety concerns in 5 countries with medication accuracy at transition of care.
• Also focuses on correct procedures, medications, communication, and infection control.

Principles of Quality Improvement

• Stem from total quality management originating in other industries, used in healthcare for measurable improvements.

Key Principles of QI

• QI works as systems and processes.
• Focuses on patients, team, and data.

QI Process

• Setting, measuring, evaluating, and improving care standards involves evaluation improvements.
• Nurse leaders and managers are critical, able to improve patient care by applying QI principles using a patient-centered approach.
• Encompasses structure, process and outcome.

QI Steps

• Step one involves what to monitor where government agencies govern standards, how care is provided and paid, and monitoring activities that fall below expected performance.
• Step two involves prioritizing monitoring of activities jeopardizing patient safety. Occurrences that have serious health consequences.
• Step three involves selecting approaches for assessment depending on the type of information needed, and avoids focusing solely on outcome measurements.
• Step four involves weaknesses in structures and processes that lead to failures.
• Step five necessitates the use of medical records, surveys, financial records, statistical reports, databases and direct observation.
• Step six includes monitoring that can be anticipatory, concurrent, or retrospective (most frequent)
• In step seven there should be activities for improving monitoring coordinated by the department or unit
• Step eight involves a behavior change with the goal of changing the structure and processes.

Models of Quality Improvement

• Donabedian, Lean, Six Sigma, IHI, FMEA, and Root Cause Analysis.

Donabedian Model

• Provides a framework to draw inferences about the quality of healthcare.
• Is a starting point for any QI activity by looking at three categories of information.

Lean Model

• Focuses on doing more with less by reducing waste
• Includes frontline nurses in QI process.
• Focuses on nonvalue-added activities, workarounds, issues, and staff empowerment.

Six Sigma

• Rigourously defines, measures, analyzes, improves, and controls to define the number of acceptable errors produced by a process.
• Improve, design, and monitor processes to minimize or reduce waste.

IHI Model of Improvement

• Asks what are we trying to accomplish, how we will know the change is improvement, and what changes will result in improvement.
• Involves plan-do-study-act cycles and small changes

Failure Modes and Effects Analysis (FMEA)

• Determines which aspect of the process needs to change and establish an action plan to prevent future failures.
• Should look at the process and make predictions about what could go wrong.

Root Cause Analysis (RCA)

• Focuses on identifying and understanding the causes of an event.
• Completed after patient safety events.
• Looks at the sequence of events, causal factors, the root cause, and an action plan.

Quality Improvement Tools

• Communicate information and determine problems
• Help with data collection, trend identification, and problem display.
• Chosen depending on the QI project.

Run Chart

• Communicates data and trends over time.
• Includes vertical and horizontal axes.
• Helps nurse managers investigate possible causes.

Bar Chart

• Common for displaying categorical data.
• Horizontal axes contain categories and frequencies, percentages are on the vertical axis.
• Managers can use to illustrate categorical data.

Histogram

• Type of bar chart to display frequency distribution
• Useful for unavailable time sequences in order to assist the team.
• Recognizing numerical chart data, finding the mean and median and illustrating length of surgical stays.

Fishbone Diagram

• Also known as an Ishikawa or cause-and-effect diagram.
• Can determine root causes and identify relationships and retrospective reviews related to outcomes.
• Can be used to investigate a medication error or event.

Pareto Chart

• Resembles a bar chart which helps determine how to work on a problem based on the 80/20 principle.

Flow Chart

• Clarifies processes, helps develop new processes, and aids in understanding.
• Shows steps, identifies complexity and non-value steps.
• Can help managers identify issues in the admission process.

Important Topics

• Culture of safety, QI principles, steps of QI process, QI models, error identification and JCO patient safety initiatives.