chapter 38 week 1.docx

+-----------------------------------+-----------------------------------+ | Learning Outcomes: | | +===================================+===================================+ | **Key Ideas** | - Quality and patient safety | |...

+-----------------------------------+-----------------------------------+ | Learning Outcomes: | | +===================================+===================================+ | **Key Ideas** | - Quality and patient safety | | | have become critical issues | | Patient safety | in health care. | | | | | Quality of care | - *"To err is Human",* pivotal | | | publication that brought | | 4 categories of harmful events | patient safety to the | | | forefront. | | Patient safety incident | | | | - **Quality of care-** the | | (Adverse event) | degree to which health care | | | services for individual and | | 3 types of incidents | population increase the | | | likelihood of desired health | | CPSI & HSO framework to improve | outcomes. | | health. | | | | - **Unintended patient harm** | | (5) | occurs **every minute and 18 | | | secs**. | | Cultural safety | | | | - **Patient death** occurs | | CPSI safety competencies | **every 13 mins and 14 | | framework (6) | secs**. | | | | | | - **[4 categories of harmful | | | events:]** | | | | | | - **1. Health care and | | | medicines** 46 %. Ex. | | | Developing bed sores or | | | receiving wrong meds. | | | | | | - **2. Infections** 30 %. | | | Ex. Surgical site | | | infections | | | | | | - **3. Procedure related** | | | 20%. Ex. Bleeding after | | | surgery | | | | | | - **4. Patient accidents** | | | 4%. Ex. Falls. | | | | | | - **Patient safety incident** | | | (adverse event) -- even that | | | could have or did result in | | | unnecessary harm to a | | | patient. | | | | | | - **[3 types of patient | | | safety | | | incidents]** | | | | | | - **1. Harmful | | | incidents**- incident | | | that results in | | | patient harm | | | | | | - **2. Near miss-** | | | incident that did | | | reach the patient, no | | | harm resulted. | | | | | | - **3. No harm | | | incident-** an | | | incident that did | | | reach the patient, | | | but no discernible | | | harm resulted. | | | | | | - The CPSI and HSO across | | | Canada developed the | | | *"Canadian quality and | | | Patient Safety Framework for | | | Health Services"* to improve | | | health for all. | | | | | | - **[Five goals establish | | | to drive patient safety | | | and | | | quality]**. | | | | | | - **1. Person centred | | | care-** people using | | | health services are | | | equal partner in | | | planning, developing, | | | and monitoring care | | | to ensure needs are | | | met and produce | | | better outcomes. | | | | | | - **2. Safe care-** | | | Service are safe and | | | free from preventable | | | harm | | | | | | - **3. Accessible | | | Care-** People have | | | timely and equitable | | | access to quality | | | services. | | | | | | - **4. Appropriate | | | Care-** Care is | | | evidence -informed | | | and person centred. | | | | | | - **5. Integrated | | | care-** health | | | services are | | | continuous and | | | well-coordinated, | | | promoting smooth | | | transitions. | | | | | | - Nurses are professionally | | | responsible for engaging in | | | activities that support | | | cultural safety. | | | | | | - **Cultural safety-** | | | outcome based on | | | respectful engagement | | | that recognizes and | | | strives to address power | | | imbalances inherent un | | | the health care system | | | including minorities Ex. | | | Black people, Indigenous, | | | LGBTQ2. | | | | | | - Emphasis placed in improving | | | the education of nursing | | | students to become competent | | | in promoting safe health care | | | practices through the *CPSI's | | | Safety Competencies | | | Framework* | | | | | | - **[Includes 6 key | | | concepts:]** | | | | | | - **1.** Patient | | | cultural safety | | | | | | - **2.** Teamwork | | | | | | - **3.** Communication | | | | | | - **4.** Safety Risk | | | and quality | | | improvement | | | | | | - **5.** Optimizing | | | human and system | | | factors | | | | | | - **6.** Recognizing, | | | responding, and | | | disclosing patient | | | safety incidents. | | | | | | - Health care in a safe manner | | | and community environment is | | | essential for patient's | | | survival and wellbeing. | | | | | | - Should incorporate | | | critical thinking skills, | | | planning and | | | intervention, | | | environmental checks, | | | health promotion and the | | | safety of nurses as they | | | provide patient care. | +-----------------------------------+-----------------------------------+ | Fostering a patient centred | - Health care organizations | | safety culture | foster a patient- centred | | | safety by: | | | | | | - Continually focusing on | | | performance improvement | | | programs | | | | | | - Acting on risk- | | | management findings and | | | safety reports | | | | | | - Providing current | | | reliable technology | | | | | | - Integrating | | | evidence-informed | | | practice into procedures | | | | | | - Designing a safe work | | | environment and | | | atmosphere | | | | | | - Providing continuing | | | education and access to | | | appropriate resources for | | | staff. | +-----------------------------------+-----------------------------------+ | Factors influencing safety | - **1. Patient and health care | | | provider factors** -- | | | characteristics of | | | individuals ex. Health, age, | | | weight, needs, moods, | | | personality, knowledge, | | | language, and cultural | | | background. | | | | | | - **2. Task factors-** task | | | that health care providers | | | must perform including the | | | tsks themselves as well as | | | their characteristics Ex. | | | Workflow, time pressure and | | | workload | | | | | | - **3. Technology Factors-** | | | technologies available within | | | an organization including | | | | | | - Number of technologies | | | | | | - Types of each | | | | | | - Their availability | | | | | | - Location | | | | | | - Ability to integrate with | | | other programs. | | | | | | - **4. Environmental Factors-** | | | safe environment reduces the | | | risk for illness and injury. | | | | | | - Physical hazards in the | | | environment place | | | patients at risk for | | | accidental injury and | | | death. | | | | | | - Unintentional injuries | | | 4^th^ leading cause of | | | death and disability | | | in 2020. | | | | | | - Falls most common for 65 | | | yrs. and older. | | | | | | - **5. Organizational | | | Factors-** the structural, | | | cultural, and policy-related | | | characteristics of the | | | institution. | | | | | | - How well it is integrated | | | into environment and | | | workflow. | | | | | | - How much training is | | | provided. | | | | | | - How users perceive it | | | ease of use ne | | | usefulness. | +-----------------------------------+-----------------------------------+ | Reasons Swiss cheese model | - Each slice of cheese | | | represents a barrier set in | | | place to make the health care | | | system safe. | | | | | | - Each safeguard contains | | | several weaknesses that are | | | represented by the holes in | | | cheese. | | | | | | - The hole continuously moves | | | around, and barriers stop | | | hazards from reaching | | | patient. | | | | | | - When the holes line up in | | | certain salutations hazards | | | sneak through and encounter | | | the patient | | | | | | - When this occurs, it is | | | called an active failure, | | | and usually multiple | | | factors are involved in | | | that failure. | | | | | | - Complex processes and | | | structures usually | | | present greater potential | | | for multiple factors and | | | latent errors in the | | | systems | +-----------------------------------+-----------------------------------+ | **Safety Analysis and improvement | - To ensure patient safety, | | techniques** | methods and techniques like | | | *root cause analysis, failure | | Root cause analysis (FCA) | mode & effect analysis, and | | | lean six stigma* exist to | | Failure mode and effect analysis | reduce and prevent errors. | | (FMEA) | | | | - Nurses must be trained in | | | systems thinking to avoid | | | errors. | | | | | | - **Root cause analysis | | | (RCA)**- retrospective | | | approach to find underlying | | | features of a situation | | | contributing to a patient | | | safety incident. | | | | | | - To identify and | | | understand all | | | contributing causes to | | | redesign the system to | | | make it safer in the | | | future. | | | | | | - Health care facilities often | | | conduct a **failure mode and | | | effect analysis (FMEA)** to | | | identify problems with | | | processes and products before | | | they occur. | | | | | | - Is a prospective approach | | | used to anticipate and | | | prevent patient safety | | | incidents through safe | | | design. | | | | | | - Knowledge from past failures | | | may contribute to foresee | | | possible failures in their | | | designs, and the deigns are | | | then adjusted, | +-----------------------------------+-----------------------------------+ | Human factors | - **Human factors --** | | | discipline dedicated to | | | identifying and correcting | | | incompatibility between | | | people, their tools, and | | | their environment. | | | | | | - Through identifying | | | incompatibility improvements | | | can be made in patient | | | efficiency, tech adoption and | | | user experience. | | | | | | - **James Reason emphasizes** | | | that you can change the | | | condition under which humans | | | work. | | | | | | - Many organizations use human | | | factor principles like | | | forcing functions to modify | | | equipment. | | | | | | - **Forcing functions-** | | | built in the design of | | | technologies to reduce or | | | avoid errors. Also ensure | | | that the person will not | | | miss key info or steps in | | | the process. | +-----------------------------------+-----------------------------------+ | TeamSTEPPS | - Program developed to provide | | | health care providers with a | | | range of strategies and | | | techniques for improving | | | teamwork. | | | | | | - Effective teamwork requires | | | successful teams, function | | | and maintaining good | | | teamwork. | +-----------------------------------+-----------------------------------+ | Risks in Health care setting | - Incidents occur when | | | something planned as part of | | CPSI & HSO framework to improve | medical care does not work | | health. | out or when inappropriate | | | care plan is used. | | \(5) \*\* | | | | - *AHRQ lists 20 tips to help | | Mentioned twice -- super | prevent medical errors*. | | important. | | | | - **"Speak up"** Campaign | | | encourages patients to take a | | | role in preventing health | | | care errors by becoming | | | active, involved, and | | | informed participants on the | | | health care team. | | | | | | - **5 goals of the HSO and CPSI | | | drive patient safety and | | | quality**: | | | | | | - **1. Person centred | | | care-** people using | | | health services are equal | | | partner in planning, | | | developing, and | | | monitoring care to ensure | | | needs are met and produce | | | better outcomes. | | | | | | - **2. Safe care-** Service | | | are safe and free from | | | preventable harm | | | | | | - **3. Accessible Care-** | | | People have timely and | | | equitable access to | | | quality services. | | | | | | - **4. Appropriate Care-** | | | Care is evidence | | | -informed and person | | | centred. | | | | | | - **5. Integrated care-** | | | health services are | | | continuous and | | | well-coordinated, | | | promoting smooth | | | transitions. | | | | | | - When potential or actual | | | patient safety incident | | | occurs the HCP must complete | | | an **incident report | | | (occurrence report**), which | | | is a confidential document | | | that completely describes the | | | incident occurred. | | | | | | - Reporting allows | | | organizations to identify | | | trends or patterns | | | throughout the facility | | | and areas to improve. | +-----------------------------------+-----------------------------------+ | Staff safety | - **Environmental Risk-** | | | various forms of chemicals | | | are a source of environmental | | | risk. | | | | | | - WHMIS set standards for | | | the control of hazardous | | | substances in workplaces | | | across Canada. | | | | | | - **WHMIS has 3 main | | | elements**: **workers | | | education programs, | | | cautionary labelling of | | | products and the | | | provisions of MSDS**. | | | | | | - **IPAC-** controlling the | | | spread of infection through | | | the consistent use of routine | | | practices helps maintain the | | | safety of patients, staff, | | | and visitors. | | | | | | - **Violence-** Factors that | | | can contribute to abusive | | | situations include | | | insufficient staffing levels, | | | violations of patient's | | | personal space due to lack of | | | privacy and provision of care | | | that requires close physical | | | contact. | +-----------------------------------+-----------------------------------+ | Patient safety | - Includes falls, procedures- | | | related accidents, and | | | equipment- related accidents. | | | | | | - **Falls** | | | | | | - Account for 90% of | | | incidents reported. | | | | | | - History of falls, gait | | | disturbance, mobility | | | difficulties, imbalances, | | | use of medications all | | | contribute to falls. | | | | | | - Another common facture | | | for risks of falls are | | | patients falling out of | | | bed in attempts to go to | | | the bathroom. | | | | | | - Fractures are the most | | | serious fall-related | | | injuries. | | | | | | - Fall can extend a | | | patient's length of stay, | | | placing them at a greater | | | risk for other | | | complications. | | | | | | - **Procedure -related | | | accidents** | | | | | | - Occurs during therapy. | | | | | | - Include medication and | | | fluid administration | | | errors, improper | | | application of external | | | devices and improper | | | performance of | | | procedures. | | | | | | - 7l5% patient affected by | | | medical errors. | | | | | | - Most common effort are | | | related to surgical | | | procedures and drug or | | | fluid administration. | | | | | | - 15.9% of these cases the | | | errors resulted in death. | | | | | | - **Equipment- Related | | | Accidents** | | | | | | - Equipment related result | | | from the malfunction, | | | disrepair, or misuse of | | | equipment, or from an | | | electrical hazard. | | | | | | - Nurses should not operate | | | equipment without | | | adequate instruction and | | | should report faulty | | | equipment and tagged it | | | to prevent future use. | +-----------------------------------+-----------------------------------+ | Risks at Developmental stages | - **1. Infant and children** | | | | | | - Unintentional injuries | | | are the leading cause of | | | death in children between | | | the ages of 1 and 14 | | | years. | | | | | | - The incidence of | | | poisoning is highest in | | | late infancy and | | | toddlerhood because of | | | children's increased | | | level of oral activity | | | and ability to explore | | | their environment. | | | | | | - **2. Adolescents** | | | | | | - In attempt to relive | | | tensions associated with | | | physical and psychosocial | | | changes as well as peer | | | pressures, adolescents | | | act impulsively and | | | engage in risk taking | | | behaviours like smoking | | | and substance abuse. | | | | | | - Inducing substances | | | increasing accidents like | | | drowning and motor | | | vehicles accidents. | | | | | | - **3. Adults** | | | | | | - Related to lifestyle | | | habits like drinking and | | | car accidents or smoking | | | and cardiovascular and | | | pulmonary diseases. | | | | | | - **4. Older persons** | | | | | | - Musculoskeletal, nervous | | | system, sensory and | | | genitourinary changes. | | | | | | - Disease like arthritis | | | and cerebrovascular | | | accidents also increase | | | the chance of injury. | | | | | | - 81 % of injuries caused | | | by falls from | | | transferring from beds, | | | chairs, and toilets, | | | getting in and out the | | | bath, slips on driveway | | | or stairs. | +-----------------------------------+-----------------------------------+ | Individual Risk Factors | - Impaired mobility | | | | | | - Sensory or communication | | | impairment | | | | | | - Lack of safety awareness | +-----------------------------------+-----------------------------------+