NUR 2206 EXAM 9
1. To Err is Human (summary)
Answer
- from IOM in 1999
- around 98,000 lives were lost each year due to medical errors
- showed people that there is a direct correlation between patient safety levels and the qualitiy
of care
- biggest outcome = in order to prevent death and injury from medical errors, dramatic changes
throughout the system must be made
- caused the creation of national center of patient safety within the Agency for Healthcare
Research and Quality (AHRQ)
- led to mandatory and voluntary reporting systems
2. 6 competencies of QSEN
Answer
1. Patient-centered care
2. Teamwork and collaboration (TEAMSTEPPS)
3. Evidence-based practice
4. Quality improvement
5. Safety
6. Informatics
3. 3 main focuses (KSAs) of the 6 competencies
Answer
1. Knowledge --> knowing identifiable risk factors
2. Skills --> demonstrate proper care to prevent infection
3. Attitude --> being confident in certain skills and constantly evaluating scenarios
,4. Categories of errors
Answer
Adverse event (AE)
- injuries caused directly by medical care
- an example is HAI
Adverse drug event (ADE)
- direct result of medication usage
- an example is a patient receiving a medication they are allergic to
Sentinel event
- type of AE that leads to death or serious harm
Medication error
- related to a mistake in prescribing, dispensing, and/or administering medications
5. Cause of errors
Answer
Root cause analysis --> identifies by working to identify under- lying problems and focusing on
the mistakes individuals make (fishbone diagram)
Reporting of errors --> blame-free reporting systems that have the aim to decrease errors
6. Error prevention strategies from most to least effective
Answer
Peer checking Checklists
Mnemonics
60-second situational awareness Patient ID
Safety-enhancing technology
7. 7 subcultures of safety (Sammer)
Answer
1. Leadership
2. Teamwork
, 3. Evidence-based
4. Communication
5. Learning
6. Just
7. Patient-centered
8. Surgical vs medical asepsis
Answer
medical asepsis
AKA clean technique, areas are considered contaminated if they bear or are suspected of
bearing pathogens
surgical asepsis
areas are considered contaminated if they are touched by any object that is not also sterile
- items are considered unsterile if they go out of your sight, are reached over, exposed to air for
a long period of time, come into contact with a wet surface
9. Sterile vs unsterile cavities
Answer
sterile cavities
- circulatory system
- urinary tract
- spinal fluid
- inside of body cavities
- brain, liver, blood
unsterile cavities
- upper respiratory tract
- GI tract
- skin, genitals, mouth, and teeth
10. Components of TeamSTEPPS
Answer
1. To Err is Human (summary)
Answer
- from IOM in 1999
- around 98,000 lives were lost each year due to medical errors
- showed people that there is a direct correlation between patient safety levels and the qualitiy
of care
- biggest outcome = in order to prevent death and injury from medical errors, dramatic changes
throughout the system must be made
- caused the creation of national center of patient safety within the Agency for Healthcare
Research and Quality (AHRQ)
- led to mandatory and voluntary reporting systems
2. 6 competencies of QSEN
Answer
1. Patient-centered care
2. Teamwork and collaboration (TEAMSTEPPS)
3. Evidence-based practice
4. Quality improvement
5. Safety
6. Informatics
3. 3 main focuses (KSAs) of the 6 competencies
Answer
1. Knowledge --> knowing identifiable risk factors
2. Skills --> demonstrate proper care to prevent infection
3. Attitude --> being confident in certain skills and constantly evaluating scenarios
,4. Categories of errors
Answer
Adverse event (AE)
- injuries caused directly by medical care
- an example is HAI
Adverse drug event (ADE)
- direct result of medication usage
- an example is a patient receiving a medication they are allergic to
Sentinel event
- type of AE that leads to death or serious harm
Medication error
- related to a mistake in prescribing, dispensing, and/or administering medications
5. Cause of errors
Answer
Root cause analysis --> identifies by working to identify under- lying problems and focusing on
the mistakes individuals make (fishbone diagram)
Reporting of errors --> blame-free reporting systems that have the aim to decrease errors
6. Error prevention strategies from most to least effective
Answer
Peer checking Checklists
Mnemonics
60-second situational awareness Patient ID
Safety-enhancing technology
7. 7 subcultures of safety (Sammer)
Answer
1. Leadership
2. Teamwork
, 3. Evidence-based
4. Communication
5. Learning
6. Just
7. Patient-centered
8. Surgical vs medical asepsis
Answer
medical asepsis
AKA clean technique, areas are considered contaminated if they bear or are suspected of
bearing pathogens
surgical asepsis
areas are considered contaminated if they are touched by any object that is not also sterile
- items are considered unsterile if they go out of your sight, are reached over, exposed to air for
a long period of time, come into contact with a wet surface
9. Sterile vs unsterile cavities
Answer
sterile cavities
- circulatory system
- urinary tract
- spinal fluid
- inside of body cavities
- brain, liver, blood
unsterile cavities
- upper respiratory tract
- GI tract
- skin, genitals, mouth, and teeth
10. Components of TeamSTEPPS
Answer
