Safety and Security Student Presentation PDF

TEACHING THE CULTURE OF SAFETY 10/28/2024 QSEN, IOM and TJC D. Filos RN, MSN How Many Die From Medical Mistakes in US Hospitals? Journal of Patient Safety September 2017 Between 210,000 – 440,000 patients...

TEACHING THE CULTURE OF SAFETY 10/28/2024 QSEN, IOM and TJC D. Filos RN, MSN How Many Die From Medical Mistakes in US Hospitals? Journal of Patient Safety September 2017 Between 210,000 – 440,000 patients 10/28/2024 suffer some type of preventable harm that contributes to their death. (Makary & Daniel, 2016) D. Filos RN, MSN (James, 2013) Medical errors are the third leading cause of death in USA (Makary & Daniel, 2016) Cost of $20 Billion dollars/year Healthcare Failures which lead to laps in safety Failure to recognize 10/28/2024 Failure to rescue Failure to plan D. Filos RN, MSN Maintaining Emergency Preparedness Avoiding Failure General Preparation to Plan Course Specific Preparation 10/28/2024 CPR Training Skills Check offs Fire Drills Simulation grading Code Pink Drills Medication Calculation D. Filos RN, MSN Preparing for mass quizzes trauma terrorism QSEN Competencies Patient-Centered Care 10/28/2024 Teamwork & Collaboration Evidence Based Practice D. Filos RN, MSN Quality Improvement Safety Informatics QSEN Defines safety as: “Minimizing risk of harm to 10/28/2024 patients and providers through both system effectiveness and D. Filos RN, MSN individual performance” Cronenwell et al. 2007 p. 128  TJC 2024 National Patient Safety Goals for Hospitals Identify patients correctly 10/28/2024 Improve staff communications Use medications safety Label Medications D. Filos RN, MSN Medication Reconciliation Use alarms safety Prevent Infection Hand hygiene Identify Patient Safety Risks Prevent Mistakes in Surgery D. Filos RN, MSN 10/28/2024  Fire Safety - RACE 10/28/2024 R—Rescue anyone in immediate danger. A—Activate the fire code and notify appropriate D. Filos RN, MSN person. C—Confine the fire by closing doors and windows. E—Evacuate patients and other people to safe area. BIG 3 in Safety Errors 10/28/2024 #1 Medication D. Filos RN, MSN Errors A medication error is a breakdown or failure at any point in the medication use process  How Many Die From Medical Mistakes in US Hospitals? 1.2 million are harmed each year by medical errors made 10/28/2024 in U.S> hospitals. Over $40 Billion annually goes toward treating the D. Filos RN, MSN consequences of medication errors. Computerized medication ordering systems can prevent 84% of dose, frequency and route errors Journal of Patient Safety, September 2013 TYPES OF Medication Errors Omission Commission Wrong drug or dose Drug not prescribed prescribed Wrong drug or dose Drug not dispensed dispensed Wrong drug administered Drug not Wrong patient administered Frequency timing or Drug not taken duration of the drug is incorrect Communication Wrong route Allergic Reaction Vague instructions Drug Interaction D. Filos RN, MSN 10/28/2024 Frequency of nursing student medication errors: A systematic review Triantafyillou et al. ,2023 Reviewed a total of 1904 nursing student medication errors Majority – wrong dose (17%) 10/28/2024 Omission (16%) Wrong time (13%) Conclusion: the frequency of nursing student medication errors is D. Filos RN, MSN high. Student Barriers to Building a Safer Culture IOM, 2013 10/28/2024 Near Miss - No harm to patient – lack of learning D. Filos RN, MSN How do we overcome these barriers? Acceptance of Corrective Feedback D. Filos RN, MSN 10/28/2024 D. Filos RN, MSN 10/28/2024 BIG 3 in Safety Errors #2 FALLS 10/28/2024 D. Filos RN, MSN One of the Never Events  Fall Demographics Females more than Falls result in 27, 000 males deaths annually Fall risk increased If you are 75 yrs. + and fall, you are 4-5 X more with age over 65 likely to be admitted to an years ECF 2.8 million older 50% die within 1 year people treated in ED Cost: $31 Billion for fall injuries Annually 800,000 patients a CDC.gov/home and recreational safety/falls year are hospitalized after falls D. Filos RN, MSN 10/28/2024 Falls Risk Factors > 65 years Old History of Falls 10/28/2024 Cognitive Impairment Altered gait Medications D. Filos RN, MSN Incontinence Unsafe Environment Sensory Deficits Orthostatic Hypotension Depression Assistive Devices Confusion or disorientation New Environment Fall Prevention Interventions Complete Fall Assessments 10/28/2024 Frequent rounding Place on Fall Precautions D. Filos RN, MSN 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 D. Filos RN, MSN 10/28/2024 Evaluation of a Patient-Centered Fall-Prevention Tool Kit to Reduce Falls and Injuries Fall TIPS A Nonrandomized Controlled Trial JAMA, November 17, 2020 Findings In this nonrandomized controlled trial including 37, 231 patients from 14 medical units within 3 academic medical center Nurse led implementation of a patient specific fall-prevention tool kit was associated with a statistically significant 15% reduction in overall inpatient falls and a 34% reduction in fall injuries 10/28/2024 D. Filos RN, MSN Big 3 in Safety Errors 10/28/2024 #3 IMPROPER USE OF D. Filos RN, MSN RESTRAINTS A Restraint is any involuntary method chemical or physical of restricting an individual's freedom of movement, physical activity, or normal access to the body ANA believes only when no other viable option is available should restraint be employed Recommended Use of Restraints Ensure the immediate physical safety of the patient, staff or others 10/28/2024 Prevent interruption of therapy D. Filos RN, MSN Prevent the confused or combative patient from removing life support equipment or unsafe attempts at mobility D. Filos RN, MSN 10/28/2024 D. Filos RN, MSN 10/28/2024 D. Filos RN, MSN 10/28/2024 The Hazards of Restraints and Side rails Impaired Circulation 10/28/2024 Altered skin integrity Altered Nutrition and Hydration D. Filos RN, MSN Aspiration/difficulty breathing Incontinence Increased possibility of serious injury due to fall Depression Anxiety Death What the Evidence Shows Routine use of restraints does not lower the risk of falls or fall injuries. They should NOT be 10/28/2024 used as a fall prevention strategy (Capezuti et al. 1996). D. Filos RN, MSN Restraints can add to the risk of fall-related injuries and deaths (Rubenstein et al. 1994). Limiting a patient’s freedom to move around leads to muscle weakness and reduces physical function (Rubenstein et al. 1997). D. Filos RN, MSN 10/28/2024 Required Documentation and Care of a Patient in Restraints Typical Policy Type of Visual ROM Circulatio Fluid/ Signs of Food Restraint Check/ n Eliminati Discomfo Psychologica on rt 10/28/2024 l Status Non-Violent Every 2 Hours Every 2 Every 2 Every2 Every 2 Every 4 One order for Hours Hours hours hours hours D. Filos RN, MSN duration of restraints Violent Every 15 min Every Every 15 Every 2 Every 4 restraints 15 Minutes Hours hours Order Q Day minute s Safety Event Reports Must be completed after any accident or incident in a health care facility that compromises safety 10/28/2024 Describes the circumstances of the accident or incident Details the patient's response to the examination and treatment D. Filos RN, MSN of the patient after the incident Completed by the nurse immediately after the incident Is not part of the medical record and completion of a Safety Event Report should not be mentioned in EMR documentation