By: Kim Peterson
Objectives

Identify nurses role in creating a safer
environment for patients.

Explain how a culture of open
acknowledgement of errors and
education is critical to improving safety.
Video

Safety
Patient Safety & Quality Care

Patient Safety…What is it?
 Do NO harm
 Freedom from accidental injury

Health care systems is prone to error




Basic system flaws
Medication error
Communication error
Timely & accurate diagnoses
Patient Deaths Related to Medical Errors
Patient Deaths Related to Preventable Medical Errors
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
1999
2013
Year
Patient Safety

Who is responsible?
 Nurse educators
 Administrators
 Researchers
 Physicians
 Government
 Accrediting agencies
 The registered nurse (RN)
Nursing Theory

Florence Nightingale
 Environmental Theory

“The very first requirement in a hospital
is that it should do the sick no harm.”
Florence Nightingale
Theory

Ronald Lippitt’s Theory of Change
 Specific & measurable
 Basis for strategic planning
 Seven step theory
Assessment of the Environment
Interventions
 Teamwork
 Education

Assessment of the Environment (cont.)
National Patient Safety Goals
 Voluntary & Mandatory Reporting
Methods
 Just Culture
 QSEN

Root Cause
Communication
Structured
Techniques:
SBAR, Time-Out,
Read Back
Teamwork
Multidisciplinary/
Multigenerational
Leadership
Vision/Mission
Role Model
Clarity
Culture of
Patient Safety
Role Model
Best Practices
Compassion
& Caring
Standardization
People
EvidenceBased
PatientCentered
Patient Safety Challenges
Changing the culture
 Accountability
 Shortage of RN’s in leadership roles

Patient Safety Outcomes
Culture of Safety
 Essential Elements
 Positive Environment

Recommendations

QSEN
 Safety
Knowledge
Skills
Value
Describe processes used in
understanding causes of error
and allocation of responsibility
and accountability (such as,
root cause analysis and failure
mode effects analysis)
Delineate general categories of
errors and hazards in care
Describe factors that create a
culture of safety (such as, open
communication strategies and
organizational error reporting
systems)
Participate appropriately in
analyzing errors and designing
system improvements
Engage in root cause analysis
rather than blaming when
errors or near misses occur
Value vigilance and monitoring
(even of own performance of
care activities) by patients,
families, and other members of
the health care team
Communicate observations or
concerns related to hazards
and errors to patients, families
and the health care team
Use organizational error
reporting systems for near
miss and error reporting
Value own role in preventing
errors
Nurses Role
Patients entitled to safe care
 ANA Standards

 Standard 8 Education
 Standard 9 EBP
 Standard 10 Quality of Practice
 Standard 12 Leadership
NCLEX Answers
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Decide to monitor IV gauges
Verbally tell the inserter that the glove is
contaminated
Have the pump refilled as soon as possible
Is demonstrating rebound tachycardia from being off
his pre-surgical beta-blocker medication
Pause the heparin infusion while the test is being
drawn in the opposite arm
Adding an additional step to the administration
procedure
The nurses’ drug guide on the handheld
communication device issued by the hospital
Administer the substitute medication
Request an order for cetirizine hydrochloride
Contact the pharmacy for a new dose that is fully
labeled
Questions or Comments
References
American Nurses Association. (2010). Nursing : Scope and standards of
practice. (2nd ed.). Silver Spring, Md.: American Nurses Association.
Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in
Nursing, 16(3), 5.
Hughes, R., (2008). Patient Safety and Quality: An evidence based handbook
for nurses. Rockville M.D.: Agency for Healthcare Research and Quality.
IOM Report: Patient Safety-Achieving a New Standard for Care. (2005).
Academic Emergency Medicine, 12(10), 1011-1012.
James, J. (2013). A new, evidence-based estimate of patient harms associated
with hospital care. Journal of Patient Safety, 9(3), 122-8.
Kohn, L., Corrigan, J., Donaldson, M., & Ebrary, Inc. (2000). To err is human
building a safer health system. Washington, D.C.: National Academy Press.
Kritsonis, A., (2004). Comparison of change theory. International Journal of
Scholarly Academic Intellectual Diversity, 8(1), 1-7.
Mccannon, J., & Berwick, D. (2011). A new frontier in patient safety. JAMA,
305(21), 2221-2.
Nursing Theory. (n.d). Retrieved March 20, 2015, from http://www.nursingtheory.org/theories-and-models/nightingale-environment-theory.php
Sammer, C., & James, B. (2011). Patient safety culture: The nursing unit
leader's role. Online Journal of Issues in Nursing, 16(3), 3.
Quality & Safety Education for Nurses (QSEN). (n.d). Retrieved March 20, 2015,
from http://qsen.org/