CONCEPT 45 SAFETY COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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]) COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 5 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 8 TYPES OF HEALTH CARE ERRORS COLLABORATIVE LEARNING #2 DISCUSS THE TYPES OF HEALTH CARE ERRORS AND PROVIDE AN EXAMPLE OF EACH. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 10 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 11 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 12 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 13 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 14 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 15 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 16 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. • COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 18 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 19 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 20 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 COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 21 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. COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 22 INTERRELATED CONCEPTS • • • • HEALTH CARE QUALITY COMMUNICATION COLLABORATION CARE COORDINATION COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 23 FEATURED EXEMPLARS • • • • • FALL PREVENTION MEDICATION ADMINISTRATION CARE COORDINATION TEAM SYSTEMS ERROR REPORTING COPYRIGHT © 2021, ELSEVIER INC. ALL RIGHTS RESERVED. 24