1. patient Safety
By: Kim Peterson

2. Objectives
Identify nurses role in creating a safer environment for patients.
Explain how a culture of open acknowledgement of errors and education is critical to improving safety.

3. Video
Safety

4. Patient Safety & Quality Care
Patient Safety…What is it?
Do NO harm
Freedom from accidental injury
Health care systems is prone to error
Basic system flaws
Medication error
Communication error
Timely & accurate diagnoses

5. Patient Deaths Related to Preventable Medical Errors
Patient Deaths Related to Medical Errors
Patient Deaths Related to Preventable Medical Errors
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
1999
2013
Year

6. Patient Safety Who is responsible? Nurse educators Administrators
Researchers
Physicians
Government
Accrediting agencies
The registered nurse (RN)

7. Nursing Theory Florence Nightingale
Environmental Theory
“The very first requirement in a hospital is that it should do the sick no harm.” Florence Nightingale

8. Theory Ronald Lippitt’s Theory of Change Specific & measurable
Basis for strategic planning
Seven step theory

10. Assessment of the Environment
Interventions
Teamwork
Education

11. Assessment of the Environment (cont.)
National Patient Safety Goals
Voluntary & Mandatory Reporting Methods
Just Culture
QSEN

12. Root Cause

13. Culture of Patient Safety
Communication
Teamwork
Leadership
Structured Techniques: SBAR, Time-Out, Read Back
Multidisciplinary/Multigenerational
Vision/Mission
Role Model
Clarity
Culture of Patient Safety
Compassion & Caring
Role Model
Best Practices
Standardization
People
Evidence-Based
Patient-Centered

14. Patient Safety Challenges
Changing the culture
Accountability
Shortage of RN’s in leadership roles

15. Patient Safety Outcomes
Culture of Safety
Essential Elements
Positive Environment

16. Recommendations QSEN Safety Knowledge Skills Value
Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as, root cause analysis and failure mode effects analysis)
Participate appropriately in analyzing errors and designing system improvements
Engage in root cause analysis rather than blaming when errors or near misses occur
Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team
Delineate general categories of errors and hazards in care
Describe factors that create a culture of safety (such as, open communication strategies and organizational error reporting systems)
Communicate observations or concerns related to hazards and errors to patients, families and the health care team
Use organizational error reporting systems for near miss and error reporting
Value own role in preventing errors
The QSEN competency defines safety as Minimizes risk of harm to patients and providers through both system effectiveness and individual performance

17. Nurses Role Patients entitled to safe care ANA Standards
Standard 8 Education
Standard 9 EBP
Standard 10 Quality of Practice
Standard 12 Leadership
continuing and improving education and holding one another accountable for the care provided for patients

18. NCLEX Answers Decide to monitor IV gauges
Verbally tell the inserter that the glove is contaminated
Have the pump refilled as soon as possible
Is demonstrating rebound tachycardia from being off his pre-surgical beta-blocker medication
Pause the heparin infusion while the test is being drawn in the opposite arm
Adding an additional step to the administration procedure
The nurses’ drug guide on the handheld communication device issued by the hospital
Administer the substitute medication
Request an order for cetirizine hydrochloride
Contact the pharmacy for a new dose that is fully labeled

19. Questions or Comments

20. References
American Nurses Association. (2010). Nursing : Scope and standards of practice. (2nd ed.). Silver Spring, Md.: American Nurses Association.
Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in Nursing, 16(3), 5.
Hughes, R., (2008). Patient Safety and Quality: An evidence based handbook for nurses. Rockville M.D.: Agency for Healthcare Research and Quality.
IOM Report: Patient Safety-Achieving a New Standard for Care. (2005). Academic Emergency Medicine, 12(10),
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care. Journal of Patient Safety, 9(3),
Kohn, L., Corrigan, J., Donaldson, M., & Ebrary, Inc. (2000). To err is human building a safer health system. Washington, D.C.: National Academy Press.
Kritsonis, A., (2004). Comparison of change theory. International Journal of Scholarly Academic Intellectual Diversity, 8(1), 1-7.
Mccannon, J., & Berwick, D. (2011). A new frontier in patient safety. JAMA, 305(21),
Nursing Theory. (n.d). Retrieved March 20, 2015, from
Sammer, C., & James, B. (2011). Patient safety culture: The nursing unit leader's role. Online Journal of Issues in Nursing, 16(3), 3.
Quality & Safety Education for Nurses (QSEN). (n.d). Retrieved March 20, 2015, from