lecture 5: patient safety + quality of care

organization that shares innovations to improve patient safety and quality of care

collaborates with pt/families/caregivers, healthcare, organization, first nations, governments

professional value

daily practice

avoidable medical incidents

health care + meds (I.e., bed sores, wrongs meds...)

infections

procedure related (I.e., bleeding out)

patient accidents (I.e., falls)

framework that identifies competencies that can be adopted and adapted by diverse healthcare programs to design curricula to teach safety + quality for any sector or healthcare program

patient safety culture

teamwork

communication

safety, risk,and quality improvement

optimize human and system factors

recognize, respond to and disclose patient safety incidents

- individuals that are committed to minimize pt harm during delivery of care

- feel comfortable speaking apt unsafe practices

- understanding one's role in enhancing a safety culture

- recognizing the importance of ongoing collaboration and commitment to advocate for change

- healthcare leaders must set clear expectations for positive safety culture and balance a "no blame system" with individual accountability

- collaboration among team members

- effective conflict resolution among team members

- value role of each member

- pt centered care

- effective communication is beneficial to pt, builds trust, and is precondition of obtaining consent

- effective verbal + nonverbal

- must collect and monitor performance data to assess risk + improve outcomes

- detects + report pt safety threats

- implements evidence informed practice

- evaluate quality improvement interventions

- optimize those that support the achievement of best human performance

- policies/procedures

- resource allocation/workload

- well being of healthcare workers

- open, honest and empathetic disclosure + appropriate apologies benefit pt, providers, organizations

- recognize/report pt safety incidents

- prevent reoccurrences

- support pt

- engage in reflection

- provide support to team members

incident: events that did not reach the pt but could have cause harm

accident: event that reached the pt whether causing harm or not

first its LEGAL obligation

primary purpose is reducing risk of occurrence of pt safety incidents in future - analyzed by institutions

identify potential factors that contributed

identify potential interventions to prevent recurrence

when occurred in course of providing care and services to a user, I.e. any undesirable situation that has or could have harmed the users' health must be reported by means of this form

as soon as possible after recognizing/discovering event

any employee of institution who witnesses/discovers/directly involved in incident/accident - includes nursing students

administers wrong meds

pt allergies known, given allergen

meds found in pt bed

meds not administered by another nurse

narcotic med missing

pt falls

near fall

pt found on floor

pt injured during application of restraints

process by which a pt is informed of an accident that has occurred - by physician

verbal communication

documentation in pt's chart

MSSS

- rapport de declaration des incidents/accidents

- rapport d'analyse des incidents/accidents

- rapport de divulgation d'accident

report

disclose

be involved

nursing documentation

- a professional responsibility

- helps ensure protection of public

relevant

concise

complete

organized

observations + assessmments

nursing analysis - health problems + goals

interventions

outcomes

required follow up

legal doc that is used to record the comprehensive assessment and care a pt receives within health care system

official means of communication among health professionals to ensure safety + continuity of care

focus on nurse's clinical decisions, provides clinical justification in reference to clients evolving condition

assessing physical + mental condition of symptomatic person

providing clinical monitoring of condition of pt whose state of health is problematic, including monitoring + adjusting the therapeutic nursing plan

providing nursing follow up for persons with complex health problems

to document nurses clinical decisions which are based in nurses assessment, which are crucial to pt follow up, tracks

separate documentation tool, part of chart, contains only priority health problems and needs that affect clinical follow up + nursing directives

one time client interventions

nurse must consult it to determine if any elements of previous TNP are relevant to new care episode

changes in clients condition - must explain the adjustments in progress notes

- requires particular clinical follow up

- will affect clinical follow up

- presents a significant change on clinical follow up

(I.e., new problem, deterioration of previous problem)

determined after nurses assessment

contains crucial indications to ensure that clinical monitoring, nursing care, Tx and other interventions the pt requires are carried out

ex: priority problem: R knee surgery

nursing directive: apply clinical pathway for R knee surgery

nurse ensure that plans are carried out by assigning tasks to team members after verifying they have the legal authority, knowledge and skills required to perform activities

work with LPNs and PABs, nursing assistants