NUR 444 - Leadership - Exam 3 Guide
With Complete Solution
"To Err is Human" Findings (MP) - ANSWER results of several studies, when
extrapolated to the 33.6 million admissions in 1997 imply that 44,000-98,000
Americans die each year as a result of medical errors
- Deaths due to medical errors exceeded the number of deaths from:
*MVC's (43,458)
*Breast Cancer (42,297)
*AIDS (16,516)
*Total National Costs of Preventable Adverse Events are estimated to be
between $17 and $29 billion annually
*½ of the costs are related health care costs
*Medication Errors:
2 out of every 100 hospital admissions experienced a preventable adverse
drug event
Most adverse drug event data was hospital based but adverse drug events
can occur in every setting
Patient Safety Initiatives (MP) - ANSWER The Joint Commission National
Patient Safety Goals began in 2003 and over the last 20 years have focused
on:
- patient identification
,- effectiveness of communication among caregivers
- safety of using medications
- medication reconciliation
- reduce the risk of health care-associated infections
- reduce the risk of harm resulting from falls (LTC)
- reduce the risk of pressure ulcers (LTC)
Identify patients at risk for suicide
- reduce the risk of home oxygen (HC)
- universal protocol for procedures
- improve the safety around device alarms
The Center for Medicare/Medicaid Services (CMS) identified certain
hospital-acquired conditions that would no longer be paid for including:
- foreign object retained after surgery
- air embolism
- blood incompatibility
- falls, trauma, injuries occurring in the hospital
- stage 3 and 4 Pressure Ulcers
- catheter-associated urinary tract infection
What are the five principles of High Reliability Organizations? (MP) -
ANSWER - Sensitivity to Operations
,- Preoccupation with Failure
- Reluctance to Simplify
- Commitment to Resilience
- Deference to Expertise
What is a Just Culture? (MP) - ANSWER A Just and Fair Culture is one that
learns and improves by openly identifying and examining its own
weaknesses; it is transparent in that those within it are as willing to expose
weaknesses as they are to expose areas of excellence.
In a Just Culture, employees feel safe and protected when voicing concerns
about safety and have the freedom to discuss their own actions, or the
actions of others in the environment, with regard to an actual or potential
adverse event.
Human error is not viewed as the cause of an adverse event, but rather a
symptom of deeper trouble in an imperfect system.
Leaders therefore do not rush to judge and punish employees involved in
medical errors, but seek first to examine the care delivery system as a whole
in order to find hidden failures and vulnerabilities.
Performance and Process Improvement Approaches (MP) - ANSWER -
Retrospective Audits
- Quality Assurance
- Reengineering and System Redesign
- Rapid-Cycle Improvement (PDSA)
- Six Sigma: DMAIC Methodology
, - LEAN: focus on reducing waste (non-value added steps)
- Transportation, Inventory, Motion, Waiting, Overproduction,
Overprocessing, Defects (creates re-work)
What is a patient safety event? - ANSWER occurs when an injury to a patient
is caused by medical management rather than the patient's underlying
condition
What is an error of omission? - ANSWER results when an action that is a
standard of care is not taken or omitted
What is an error of commission? - ANSWER results when the wrong action is
taken or committed
What is unsafe act? - ANSWER occurs in the presence of a potential hazard,
sometimes as the result of a violation, not an error
What are slips, lapses, and mistakes? - ANSWER actions that do not result in
the intended outcome
What is a near miss? - ANSWER a potential error that was discovered before
it was carried out
What is a sentinel event? - ANSWER a patient safety event that results in
death, permanent harm, or severe temporary harm. Sentinel events are
debilitating to both patients and health care professionals
What is an adverse event? - ANSWER an unexpected medical problem that
happens during treatment. Adverse events may be mild, moderate, or severe
What is a never event? - ANSWER serious and costly errors in the provision of
health care services that should never happen
With Complete Solution
"To Err is Human" Findings (MP) - ANSWER results of several studies, when
extrapolated to the 33.6 million admissions in 1997 imply that 44,000-98,000
Americans die each year as a result of medical errors
- Deaths due to medical errors exceeded the number of deaths from:
*MVC's (43,458)
*Breast Cancer (42,297)
*AIDS (16,516)
*Total National Costs of Preventable Adverse Events are estimated to be
between $17 and $29 billion annually
*½ of the costs are related health care costs
*Medication Errors:
2 out of every 100 hospital admissions experienced a preventable adverse
drug event
Most adverse drug event data was hospital based but adverse drug events
can occur in every setting
Patient Safety Initiatives (MP) - ANSWER The Joint Commission National
Patient Safety Goals began in 2003 and over the last 20 years have focused
on:
- patient identification
,- effectiveness of communication among caregivers
- safety of using medications
- medication reconciliation
- reduce the risk of health care-associated infections
- reduce the risk of harm resulting from falls (LTC)
- reduce the risk of pressure ulcers (LTC)
Identify patients at risk for suicide
- reduce the risk of home oxygen (HC)
- universal protocol for procedures
- improve the safety around device alarms
The Center for Medicare/Medicaid Services (CMS) identified certain
hospital-acquired conditions that would no longer be paid for including:
- foreign object retained after surgery
- air embolism
- blood incompatibility
- falls, trauma, injuries occurring in the hospital
- stage 3 and 4 Pressure Ulcers
- catheter-associated urinary tract infection
What are the five principles of High Reliability Organizations? (MP) -
ANSWER - Sensitivity to Operations
,- Preoccupation with Failure
- Reluctance to Simplify
- Commitment to Resilience
- Deference to Expertise
What is a Just Culture? (MP) - ANSWER A Just and Fair Culture is one that
learns and improves by openly identifying and examining its own
weaknesses; it is transparent in that those within it are as willing to expose
weaknesses as they are to expose areas of excellence.
In a Just Culture, employees feel safe and protected when voicing concerns
about safety and have the freedom to discuss their own actions, or the
actions of others in the environment, with regard to an actual or potential
adverse event.
Human error is not viewed as the cause of an adverse event, but rather a
symptom of deeper trouble in an imperfect system.
Leaders therefore do not rush to judge and punish employees involved in
medical errors, but seek first to examine the care delivery system as a whole
in order to find hidden failures and vulnerabilities.
Performance and Process Improvement Approaches (MP) - ANSWER -
Retrospective Audits
- Quality Assurance
- Reengineering and System Redesign
- Rapid-Cycle Improvement (PDSA)
- Six Sigma: DMAIC Methodology
, - LEAN: focus on reducing waste (non-value added steps)
- Transportation, Inventory, Motion, Waiting, Overproduction,
Overprocessing, Defects (creates re-work)
What is a patient safety event? - ANSWER occurs when an injury to a patient
is caused by medical management rather than the patient's underlying
condition
What is an error of omission? - ANSWER results when an action that is a
standard of care is not taken or omitted
What is an error of commission? - ANSWER results when the wrong action is
taken or committed
What is unsafe act? - ANSWER occurs in the presence of a potential hazard,
sometimes as the result of a violation, not an error
What are slips, lapses, and mistakes? - ANSWER actions that do not result in
the intended outcome
What is a near miss? - ANSWER a potential error that was discovered before
it was carried out
What is a sentinel event? - ANSWER a patient safety event that results in
death, permanent harm, or severe temporary harm. Sentinel events are
debilitating to both patients and health care professionals
What is an adverse event? - ANSWER an unexpected medical problem that
happens during treatment. Adverse events may be mild, moderate, or severe
What is a never event? - ANSWER serious and costly errors in the provision of
health care services that should never happen
