QI & PS

To Err is Human (1999)
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Terms in this set (28)
To Err is Human (1999)
"The health care system was causing an many deaths as three fully loaded jumbo jets crashing and killing everyone on board every other day" (McGiffert)

-44,000-98,000 preventable deaths each year due to medical errors & system failures
STEEEP (6)
-Safe
-Timely: reducing wants and sometimes harmful delays
-Effective: providing appropriate level of services based on scientific knowledge
-Efficient: avoiding waste of supplies, ideas, and energy
-Equitable
-Pt Centered Care
Joint Commission established National Patient Safety Goals (2002)
-specific actions to prevent and reduce serious medical errors and sentinel events
Common Agenda per National Quality Strategy (USDHHS)
-improve health
-improve experience
-affordable
Interchangeable Concepts
-Total quality management (TQM)
-Quality improvement (QI)
-Process improvement (PI)
Quality Improvement (service not delivered)
-systematic process
-continuous
-prospective approach
-doing the right thing
-EVERYONE responsible
Quality Assurance (service delivered)
-inspection approach
-retrospective
-reactive
-standards met?
-Examples: chart audits, variance/incident reports
-FEW responsible
Nurse-sensitive indicators
-Structure: supply of nursing staff, skill level, and education/certification of staff
-Process: aspects of nursing care (assessment, intervention, and job satisfaction)
-Outcomes of nursing care - falls, pressure ulcers, IV infiltration
Nursing Database of Nursing Quality Indicators (NDNQI)
collects data and establishes benchmarks (unit)

ie. patient falls, pressure ulcers, staff mix, turnover, etc.
Standards of Care
describe minimum acceptable nursing care

-ie. ANA Standards of Nursing Practice, Joint Commission, QSEN, IOM, State Nurse Practice Act, etc.
Benchmarking-process of measuring against "best performing organizations" *Internal benchmarking*: using data from within the organization as a comparison (ie. units in same hospital) *External benchmarking*: compares what you are doing against what others are doing (ie. top performers across the country)QI Methodologies*PDSA: Rapid Cycle Test* *Six Sigma*: goal to reduce variation in existing process *DMAIC*: problem-solving steps to reduce variation (define, measure, analyze, improve, and control) *Lean Six Sigma*: reduce variation + eliminate waste8 Common Steps in QI1. Purpose 2. Literature 3. Current Resources 4. Current Processes 5. Root causes 6. Select appropriate tools 7. Select measures and metrics (baseline and outcomes) 8. PDSA (rapid cyclical review)Root Cause AnalysisWhat happened, why, and how to preventCause and Effect/Fish bone diagramhorizontal arrows - issues (ie. floor is wet, no handrails, nurses not rounding) diagonal arrows - potential cause (ie. Equipment, People, Methods)PDCA (plan, do, check, act)/Rapid Cycle Reviewencourages continuous and ongoing efforts to improve outcomes *Plan* - define objective, questions, and predictions *Do* - carry out the plan, collect data *Study* - complete analysis of the data, compare to predictions, summarize knowledge *Act* - plan next cycle, decide whether change can be implementedError-failure of planned action to be completed as intended or the use of the wrong plan to achieve an aim *Latent error* - GREATEST THREAT, dormant problems within the system *Active error* - non-compliant with procedure or making a mistakeMisuseavoidable complications that prevent patients from receiving full potential benefit of a service (ie. patient receives a med not prescribed and conflicts w/ allergies)Overusepotential for harm from the provision of a service that exceeds the possible benefit (ie. Elderly put on multiple meds and multiple healthcare providers do not know meds have been prescribed)Adverse eventinjury resulting from medical intervention, not due to underlying conditionFailure to rescueprevent clinically important deterioration from a complication of an underlying illness or complication of medical care (ie. IV beeps, but no one checks; ventilator alarms)Near-missrecognition that an event occured that might have led to an adverse eventSentinel eventevent that had a negative patient outcome (unexpected death, serious physical/psychological injury, serious risk) ie. pt commits suicide in hospital for treatment of diabetes or depressionHuman factors engineeringhuman element to make product and processes safer to use *unconscious*: forgetting to give a medication, picking up wrong syringe *conscious*: work-aroundsBarriers to error reporting-inability to recognize errors -burdensome documentation -lack of anonymity -hesitancy -unclear reporting requirements for errors w/o adverse outcome -fear of lawsuits -perception that change will not occurCulture of safetyblame-free environment in which staff can practice and openly discuss potential errors or near-misses as well as actual errorsJust Culture"No shame! No blame!" accountabilitySafe Harbor Act-must be done in good faith -protect patients and maintain professional status