Questions and Answers 100% Pass
IOM 4th core competencies - ✔✔Apply quality improvement - identify errors and
hazards and to implement basic safety design principles
- measured in terms of structure, process, and outcomes
- design and test interventions to change processes and systems of care
TJC definition of quality improvement - ✔✔Approach to the continuous study and
improvement of the process of providing health care services to meet needs of patients
J CO - ✔✔Independent organization that accredits hospitals; set high standards for
hospitals to increase quality of care
To err is human - ✔✔report that has led to increase awareness of med errors
- 44,000 americans die each year from med errors more ppl die from med errors than
AIDS, breast cancer
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,Nursing safety and quality improvement issues - ✔✔- needle sticks
- infections ; bacterial and viral
- violence
- chemical exposure
Hospital acquired complications - ✔✔- falls
- decubiti
- performing wrong surgery
- air embolism
- CAUTI
- foreign object retained after surgery
Sentinel event - ✔✔Event resulting in harm to a patient
Safety - ✔✔freedom from accidental injury
Adverse event - ✔✔injury from medical intervention ie wrong medication
Misuse - ✔✔given medication one is allergic to
Overuse - ✔✔Elderly patient given multiple meds ands providers not communicating
Underuse - ✔✔insurance will not cover a medicine
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, Near miss - ✔✔pt is scheduled to have a right leg surgery but left leg is prepped -
caught before it happens
Root Cause analysis - ✔✔in depth analysis of an error to try to find out what happens;
doesnt ask who
No harm event - ✔✔Patient safety event that doesnt effect patient
Patient safety net (PSN) - ✔✔incident reporting system
adverse events
near miss
sentinel events
Harm scores - ✔✔The higher the number the worse the outcome
TJC root cause analysis matrix - ✔✔what happened?
why did it happen?
what were the most proximate factors?
what systems & processes underlie those proximate factors?
Tools and methods to monitor and improve health care - ✔✔- standards of care
- policies and procedures
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