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Ch. 45 Safety Lecture-2

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CONCEPT 45
SAFETY
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CONCEPTS FOR
NURSING
PRACTICE, 3RD
EDITION
LESSON 45.1
SAFETY
1.
2.
3.
DEFINE AND DESCRIBE THE CONCEPT OF SAFETY.
DISCUSS THE UNDERLYING THEORY OF SAFETY.
IDENTIFY SAFETY IN THE NURSING AND HEALTH CARE PRACTICE.
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2
DEFINITION
(1 OF 2)
•
SAFETY IS “FREEDOM FROM ACCIDENTAL INJURIES; ENSURING
PATIENT SAFETY INVOLVES THE ESTABLISHMENT OF OPERATIONAL
SYSTEMS AND PROCESSES THAT MINIMIZE THE LIKELIHOOD OF
ERRORS AND MAXIMIZES THE LIKELIHOOD OF INTERCEPTING
THEM WHEN THEY OCCUR.”
IOM—TO ERR IS HUMAN, 2000
•
SAFE CARE IS “AVOIDING INJURIES TO PATIENTS FROM THE
CARE THAT IS INTENDED TO HELP THEM.”
IOM—CROSSING THE QUALITY CHASM, 2001
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3
DEFINITION
(2 OF 2)
•
•
SAFE CARE “INVOLVE[S] MAKING EVIDENCE-BASED CLINICAL
DECISIONS TO MAXIMIZE THE HEALTH OUTCOMES OF AN INDIVIDUAL
TO MINIMIZE THE POTENTIAL FOR HARM.” (KEEPING PATIENTS SAFE,
2004)
PATIENT SAFETY IS THE “PREVENTION OF HEALTHCARE ERRORS, AND
THE ELIMINATION OR MITIGATION OF PATIENT INJURY CAUSED BY
HEALTHCARE ERRORS.” (NATIONAL PATIENT SAFETY FOUNDATION
[NPSF])
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4
LEVELS OF ERRORS
(1 OF 2)
•
•
ADVERSE EVENT
•
NEAR MISS
•
•
•
UNINTENDED HARM BY AN ACT OF COMMISSION OR OMISSION RATHER
THAN AS A RESULT OF DISEASE PROCESS
ERROR OF COMMISSION OR OMISSION THAT COULD HAVE HARMED A
PATIENT, BUT HARM DID NOT OCCUR AS A RESULT OF CHANCE
COMMISSION (DID NOT PROVIDE CARE CORRECTLY) OR OMISSION (DID
NOT PROVIDE CARE) THAT COULD HAVE HARMED THE PATIENT, BUT
SERIOUS HARM DID NOT OCCUR AS A RESULT OF CHANCE
SENTINEL EVENT
•
UNEXPECTED OCCURRENCE INVOLVING DEATH OR SERIOUS PHYSICAL OR
PSYCHOLOGICAL INJURY, INCLUDING LOSS OF LIMB OR FUNCTION.
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LEVELS OF ERRORS
(2 OF 2)
COLLABORATIVE LEARNING #1
THINK ABOUT EXAMPLES OF EACH LEVEL OF ERROR THAT YOU HAVE
SEEN OR HEARD ABOUT IN THE HEALTH CARE SETTING.
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6
SAFETY
IN NURSING, SAFETY HAS FOCUSED ON THE
SAFE EXECUTION OF SPECIFIC PROCEDURES
AND TASKS. HOWEVER, RECENT SAFETY
WORK HAS EMPHASIZED THE VARIETY OF
ERRORS THAT COMPROMISE PATIENT SAFETY
AND THE RANGE OF VARIABLES THAT IMPACT
THE OCCURRENCE OF ERRORS IN HEALTH
CARE. UNDERSTANDING TYPES OF ERRORS IN
HEALTH CARE IS A VITAL ELEMENT IN
ADDRESSING INDIVIDUAL PRACTICE AND
IMPROVING HEALTHCARE SYSTEMS
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7
SCOPE AND CATEGORY OF CONCEPT
•
CATEGORIES OF ERRORS
•
•
•
•
•
TREATMENT- ERROR THAT OCCURS IN THE PERFORMANCE OF AN OPERATION, PROCEDURE OR TEST. AVOIDABLE
DELAY IN TREATMENT OR DELAY IN RESPONDING TO ABNORMAL TESTS
PREVENTIVE- FAILURE TO PROVIDE ADEQUATE TREATMENT AND MONITORING
COMMUNICATION- LACK OF COMMUNICATION OR CLARITY
SCOPE OF ERRORS
•
•
•
DIAGNOSTIC- ERRORS ARE THE RESULT OF A DELAY IN DIAGNOSIS, FAILURE TO EMPLOY INDICATED TESTS, USE
OF OUTMODED TESTS, OR FAILURE TO ACT ON RESULTS OF MONITORING OR TESTING.
LATENT- A LATENT FAILURE IS A FLAW IN A SYSTEM THAT DOES NOT IMMEDIATELY LEAD TO AN ACCIDENT BUT
ESTABLISHES A SITUATION IN WHICH A TRIGGERING EVENT MAY LEAD TO AN ERROR.1
ACTIVE- COMPLETING THE WRONG TREATMENT OR PROCEDURE (GIVING WRONG MEDICATION, ACTIVE AND LEAD
TO LATENT ERRORS.
FOUNDATIONAL DOMAINS FOR ERROR PREVENTION. THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI) WROTE A
REPORT THAT FOCUSED ON -THE REPORT EMPHASIZES THAT IN ADDITION TO TEACHING INDIVIDUALS AND TEAMS,
ADVANCES ARE NEEDED FOR DESIGNING SAFER HEALTHCARE SYSTEMS TO ADDRESS THE MANY KINDS OF ERRORS THAT
OCCUR.
•
•
HEALTHCARE CULTURE
LEARNING SYSTEM
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TYPES OF HEALTH CARE ERRORS
COLLABORATIVE LEARNING #2
DISCUSS THE TYPES OF HEALTH CARE ERRORS AND PROVIDE AN
EXAMPLE OF EACH.
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9
ORGANIZATIONAL CULTURE OF
SAFETY
•
•
•
HISTORICALLY, A CULTURE OF BLAME HAS EXISTED; IDENTIFY THE CLINICAL AT
FAULT, FOLLOWED BY DISCIPLINARY MEASURES.
NOW—THE FOCUS IS ON WHAT WHEN WRONG RATHER THAN WHO TO BLAME.
CULTURE OF SAFETY IS NEEDED TO ADDRESS ERRORS AND TO PREVENT A
REOCCURRENCE.
•
WHEN ERRORS OR NEAR MISSES OCCUR, THE FOCUS IS ON WHAT WENT WRONG
RATHER THAN ON WHO COMMITTED THE ERROR. THE FOCUS SHIFTS FROM
IDENTIFYING FAULT TO ESTABLISH BLAME AND DETERMINE DISCIPLINE TO
ACKNOWLEDGING AND REPORTING ERRORS AND NEAR MISSES TO IMPROVE THE
SYSTEM. ACCOUNTABILITY IS A CRITICAL ASPECT OF A CULTURE OF SAFETY;
RECOGNIZING AND ACKNOWLEDGING ONE’S ACTIONS IS A TRADEMARK OF
PROFESSIONAL BEHAVIOR.
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RIGHTS RESERVED.
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QSEN ATTRIBUTES OF SAFETY
(QUALITY AND SAFETY EDUCATION FOR NURSES)
KNOWLEDGE
• FOCUS OF SAFETY IS ON THE EXECUTION OF SKILLS, AS WELL AS ON
TECHNOLOGY AND SYSTEMS LEVEL.
CONTEMPORARY NURSES NEED TO BE KNOWLEDGEABLE IN
EXAMINING HUMAN FACTORS AND OTHER BASIC SAFETY DESIGN PRINCIPLES AS
WELL AS MAKE THE DISTINCTION WITH COMMONLY USED UNSAFE PRACTICES
(E.G., WORKAROUNDS AND DANGEROUS ABBREVIATIONS). NURSES NEED TO BE
ABLE TO DESCRIBE THE BENEFITS AND LIMITATIONS OF SELECTED SAFETYENHANCING TECHNOLOGIES (E.G., BARCODES, COMPUTERIZED PROVIDER ORDER
ENTRY, MEDICATION PUMPS, AND AUTOMATIC ALERTS/ALARMS). EDUCATING
NURSES IN EFFECTIVE STRATEGIES TO REDUCE RELIANCE ON MEMORY (E.G.,
CHECKLISTS) ENCOURAGES NURSES TO UNDERSTAND SAFETY AS AN INDIVIDUAL
AS WELL AS A SYSTEMS PHENOMENON.
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SKILLS
•
SKILLS -NURSES NEED TO USE TOOLS TO CONTRIBUTE TO SAFER SYSTEMS.
FOR EXAMPLE, NURSES MUST DEVELOP SKILLS IN THE EFFECTIVE USE OF
TECHNOLOGY AND STANDARDIZED PRACTICES THAT SUPPORT SAFETY AND QUALITY AS WELL
AS EFFECTIVELY USE STRATEGIES TO REDUCE RISK OF HARM TO SELF OR OTHERS.
COMMUNICATION FAILURES ARE THE LEADING CAUSE OF INADVERTENT PATIENT HARM.23 IT
IS VITAL FOR NURSES TO DEVELOP SKILLS TO COMMUNICATE OBSERVATIONS OR CONCERNS
RELATED TO HAZARDS AND ERRORS TO PATIENTS, FAMILIES, AND THE HEALTHCARE TEAM.
NURSES’ ABILITY TO ENGAGE PATIENT PARTICIPATION IN SAFETY MEASURES IS AN
ESSENTIAL ELEMENT OF EFFECTIVE PATIENT PARTICIPATION AND IMPROVES
OUTCOMES.24 NURSES HAVE THE RESPONSIBILITY TO USE ORGANIZATIONAL ERRORREPORTING SYSTEMS FOR NEAR MISS AND ERROR REPORTING AND TO PARTICIPATE IN
ANALYZING ERRORS AND DESIGNING SYSTEM IMPROVEMENTS
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ATTITUDES
•
ATTITUDES
• NURSES AND OTHER HEALTH CARE PROFESSIONALS NEED TO VALUE THEIR ROLES IN
SAFETY AND COLLABORATION.
NURSES’ PERSONAL AND PROFESSIONAL ATTITUDES ARE INSTRUMENTAL IN SHAPING THEIR
NURSING PRACTICE AND RECOGNIZING THE COGNITIVE AND PHYSICAL LIMITS OF HUMAN
PERFORMANCE.
PROFESSIONAL'S VALUE THEIR OWN ROLE IN PREVENTING ERRORS AND REALIZE THE
DIFFERENCE THAT ONE PERSON CAN MAKE IN PREVENTION, EVEN FOR ONE PATIENT AND
FAMILY.
DEVELOPING AN ATTITUDE OF COLLABORATION ACROSS THE HEALTHCARE TEAM TO ENSURE
SAFE COORDINATION OF CARE CONTRIBUTES TO SAFE CARE. IT IS THE COLLECTIVE AND
SHARED ENVIRONMENTAL SCANNING AND VIGILANCE BY ALL TEAM MEMBERS.
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HUMAN FACTORS
•
•
•
•
IS THE STUDY OF THE INTERRELATIONSHIPS AMONG PEOPLE,
TECHNOLOGY, AND THE WORK ENVIRONMENT.
CONSIDER THE ABILITY OR INABILITY TO PERFORM TASKS WHILE
ATTENDING TO MULTIPLE THINGS AT ONCE.
WORK OF NURSES IN ACUTE CARE ENVIRONMENT IS VERY COMPLEX.
FOCUS IS ON SUPPORTING HEALTH PROFESSIONALS AND
ELIMINATING HAZARDS.
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HUMAN FACTOR
DEVELOPMENT OF SYSTEMS THAT DO NOT RESPOND
REACTIVELY TO ERROR OCCURRENCE BUT INSTEAD WORK
PROACTIVELY TO AVOID ERRORS IN AN ANTICIPATORY WAY
THROUGH THE PURPOSEFUL DESIGN OF SAFER SYSTEMS.
A CULTURE OF SAFETY REQUIRES ORGANIZATIONAL
LEADERSHIP THAT GIVES ATTENTION TO HUMAN FACTORS SUCH AS
MANAGING WORKLOAD FLUCTUATIONS, SEEKING STRATEGIES TO
MINIMIZE INTERRUPTIONS IN WORK, AND ATTENDING TO
COMMUNICATION AND COORDINATION ACROSS DISCIPLINES
INCLUDING POWER GRADIENTS AND EXCESSIVE PROFESSIONAL
COURTESY.
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CREW RESOURCE MANAGEMENT
•
•
•
EMPHASIZES THE ROLE OF HUMAN FACTORS IN HIGH-STRESS, HIGHRISK WORK ENVIRONMENT
USED TO IMPROVE TEAM FUNCTIONING IN OPERATING ROOMS,
EMERGENCY DEPARTMENTS, LABOR AND DELIVERY, AND
PERIOPERATIVE AREAS
TAILORED TO FIT AN INDIVIDUAL ORGANIZATION AND ITS SPECIFIC
HUMAN FACTORS THAT CONTRIBUTE TO ERRORS AND NEAR MISSES
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HIGH-RELIABILITY ORGANIZATIONS
•
•
•
•
•
MANAGE WORK THAT INVOLVES HAZARDOUS ENVIRONMENTS
CHARACTERISTICS OF THE HRO MINDSET
HROS EXHIBIT SENSITIVITY TO OPERATIONS. BEYOND POLICIES AND MANUALS, THERE IS A
“SITUATIONAL AWARENESS” AMONG HROS IN WHICH PROCESS ANOMALIES AND OUTLIERS
ARE QUICKLY IDENTIFIED. SENSITIVITY TO OPERATIONS BOTH REDUCES THE NUMBER OF
ERRORS AND FACILITATES PROMPT RECOGNITION TO AVOID LARGER CONSEQUENCES FROM
ERRORS.
• HROS ARE PREOCCUPIED WITH FAILURE AND FOCUSED ON PREDICTING AND ELIMINATING
ERRORS RATHER THAN BEING IN THE POSITION OF REACTING TO ERRORS. HROS VIEW NEAR
MISSES AS OPPORTUNITIES TO IMPROVE CURRENT SYSTEMS BY EXAMINING STRENGTHS
AND WEAKNESSES AND ADDRESSING GAPS.
•
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17
HROS CONT.
•
•
•
•
HROS HAVE A RELUCTANCE TO SIMPLIFY. THESE HIGH-FUNCTIONING ORGANIZATIONS
ACCEPT THE COMPLEXITY INHERENT IN THEIR WORK AND DO NOT ACCEPT SIMPLISTIC
SOLUTIONS FOR CHALLENGES INTRINSIC TO COMPLEX SYSTEMS. IN COMPLEX WORK
ENVIRONMENTS, DIFFERENT TEAM MEMBERS MAY HAVE INFORMATION AT DIFFERENT
TIMES.
• EFFECTIVE HROS EXHIBIT DEFERENCE TO EXPERTISE AND CULTIVATE A CULTURE IN WHICH
TEAM MEMBERS AND ORGANIZATIONAL LEADERS DEFER TO THE PERSON WITH THE MOST
KNOWLEDGE OF THE CURRENT ISSUE OR CONCERN. THE TEAM MEMBER WITH THE MOST
INFORMATION MAY NOT BE THE INDIVIDUAL WITH THE HIGHEST RANK, DEEMPHASIZING
HIERARCHY.
• HROS EXHIBIT A COMMITMENT TO RELIANCE. HROS PAY CLOSE ATTENTION TO THEIR
ABILITY TO QUICKLY CONTAIN ERRORS AND RETURN TO FUNCTIONING DESPITE
SETBACKS.32
EXPLICIT VALUE OF SAFETY AT AN ORGANIZATIONAL LEVEL
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JUST CULTURE
•
•
•
A HEALTH CARE SYSTEM’S VALUE IS IN REPORTING ERRORS
WITHOUT PUNISHMENT
“JUST CULTURE” SEEKS TO FIND A BALANCE BETWEEN THE NEED TO
LEARN FROM MISTAKES AND THE NEED FOR DISCIPLINARY ACTION
AGAINST EMPLOYEES
CONSEQUENCES FOR ERRORS ADDRESSED BY MARX MODEL: HUMAN
ERROR VS. AT-RISK VS. RECKLESS BEHAVIOR
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JUST CULTURE
•
•
•
•
•
AT-RISK BEHAVIOR IS BEHAVIORAL CHOICE THAT INCREASES RISK WHEN RISK
IS NOT RECOGNIZED OR IS MISTAKENLY BELIEVED TO BE JUSTIFIED.
RECKLESS BEHAVIOR IS A BEHAVIOR CHOICE TO CONSCIOUSLY DISREGARD A
SUBSTANTIAL RISK. EACH LEVEL OF ERROR INVOLVES DIFFERING RESPONSES
FROM LEADERSHIP.
HUMAN ERROR IS BEST REMEDIED BY TRAINING, REDESIGNING THE SYSTEM,
AND IMPROVING PROCEDURES.
AT-RISK BEHAVIOR IS BEST MITIGATED BY CREATING INCENTIVES FOR
HEALTHY BEHAVIORS, INCREASING SITUATIONAL AWARENESS, AND PROVIDING
EDUCATION.
MARX SUGGESTS REMEDIAL OR PUNITIVE ACTION IN INSTANCES OF RECKLESS
BEHAVIOR.
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TRANSPARENCY IN HEALTH CARE
•
•
•
AVAILABLE INFORMATION: SYSTEMS PERFORMANCE ON SAFETY,
EVIDENCE-BASED PRACTICE, PATIENT SATISFACTION
OPEN COMMUNICATION WITH PATIENTS AND FAMILY
DISCLOSURE IS A KEY PART OF TRANSPARENCY
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TRANSPARENCY AND DISCLOSURE
COLLABORATIVE LEARNING #
SHARE A SITUATION IN WHICH AN ERROR WAS DISCLOSED TO YOU AND
ONE IN WHICH IT WAS NOT.
COMPARE AND CONTRAST THESE SITUATIONS, SPECIFICALLY NOTING
HOW YOU FELT WHEN THE DISCLOSURE WAS MADE VERSUS WHEN YOU
FOUND OUT.
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INTERRELATED CONCEPTS
•
•
•
•
HEALTH CARE QUALITY
COMMUNICATION
COLLABORATION
CARE COORDINATION
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23
FEATURED EXEMPLARS
•
•
•
•
•
FALL PREVENTION
MEDICATION ADMINISTRATION
CARE COORDINATION
TEAM SYSTEMS
ERROR REPORTING
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