quality of care
A level of excellence of care based upon pre-established criteria.
Preventable healthcare errors
400,000 people in the US hospitals die from preventable healthcare errors every year making this the third leading cause of death
Culture of Safety includes:
Development and support of a proactive approach rather than a reactive, blaming approach.
A sense of trust among team members.
Dissemination and verification of receipt of information to all levels of staff and management.
A sincere commitment to affirmin
Near misses/ close calls
Event where in error was likely to occur if the situation had not been corrected
Root Cause Analysis
technique for identifying prevention of error strategies and developing a culture of safety
just culture
refers to an organization's commitment to accountability and a focus supporting universal safety in health care
US Department of labor occupational safety and health administration
Establishes regulations for safety and the physical work environment such as air quality ergonomics prevention of infection transmission from Needles exposure to toxic substances
The Joint Commission (TJC)
An organization that accredits health care organizations and programs
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Group of agencies that establish standards for hospitals and health organizations which they apply during inspections that lead to accreditation
National Safety Goals
specific aims that address major risks to patients as identified by the Institute for Healthcare Improvement
Patient identification, effectiveness of communication, safety of medications, clinical alarm systems, healthcare associated infections, safety ri
Sentinel events
Unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof.
Quality and Safety Education for Nurses (QSEN)
developed to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the health care systems within which they work
-minimizes risk of harm to patients and
Institute of Medicine competencies
Knowledge skills and attitudes
Patient centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
incident report
a means of documenting problem events within a hospital or other medical facility
Six rights of medication administration
1. Right medication
2. Right dose
3. Right patient
4. Right route
5. Right time
6. Right documentation
Tall man letters are used for drugs which:
have look-alike names
Healthcare worker risks
Exposure to blood-borne pathogen's, back injuries, over exposure to anti-neoplastic medications, threat of violence and assault from patients and visitors
Green teams
Team created in hospitals to identify areas of polluting waist and do a secondary recovery
General tools for quality and safety improvement
Mistake proofing
Checklists
Successive checks or double checking
bundles
evidence-based best practices that have proven positive outcomes when implemented together to prevent infection
CLABSI
central line associated blood stream infection
CLABSI prevention
Hand hygiene, chlorhexidine skin prep, full-barrier precautions (mask, patient head turned away), avoid femoral vein, take out catheters as soon as possible, daily assessment of catheters
never events
Serious but preventable errors that should never occur
Latent errors" are best defined as:
Defects in the design and organization of processes and systems.