NUR 2206 Exam 3
1. NASEM
Answer National Academies of Sciences, Engineering, Medicine
2. AHRQ
Answer Agency for Healthcare Research and Quality
Team strategies and Tools to enhance performance and patient safety( teamstepps)
3. QESN
Answer Quality and Safety Education for Nurses
4. ISMP
Answer Institute for Safe Medication Practices
- To err is human
Answer challenged the healthcare system to focus on medical errors
- TeamSTEPPS
Answer Team Strategies and Tools to Enhance Performance and Patient Safety
- QESN goals
Answer Patient Centered Care
- Including pts/families in all healthcare decision making 1 / 4
• Teamwork and Collaboration
- SBAR / Rapid Response Teams
- Bundles and Protocols
- Culture of Safety
- Medical Reconciliation - Warm Handoffs
- Use of Databases and Dashboards
• Evidence Based Practice
• Quality Improvement
• Safety
• Informatics
- AHRQ goals
Answer Produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable
• Works within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used • TeamSTEPPS - training to improve teamwork and communication - AHRQ Initiative
- Leadership Strategy
Answer Planning, problem solving, process improvement
- Planning/Brief
Answer short session prior to start to discuss team formation; assign roles, establish expectations and climate and to attempt to anticipate outcomes and likely contingencies
- problem solving/ huddle
- Process improvement/debrief
Answer ad hoc planning to re-establish situational aware- ness, reinforcing plans already in place and assessing need for any adjustments
Answer 2 / 4
informal information exchange session de- signed to improve team performance and effectiveness; after action review
- situation monitoring process
Answer is the process of continual scanning your envi- ronment - what's going on around you - Situational Awareness Creates shared mental model so all are on the "same page" Occurs during a procedure or event.Should precede mutual support and be used by all team members
- TeamSTEPPS - STEP
Answer is a tool for monitoring situations in the delivery of health care.
Status - Pt Hx, VS, Meds, PE, Plan of Care, ?Psych Issues Team - Fatigue, Workload, Task Performance, Skill, Stress Environment - Facility Info, Admin Info, Human Resources, Ability to Triage Acuity. Equipment Progress - What is the status of Team's pts, Do we have established goals for the Team?, What are the Teams tasks / priority actions, Evaluate - is plan still appropriate?
- Cross monitoring
Answer Team Members can employ an error reduction strategy that is called CROSS MONITORING
- Monitoring actions of other team members to provide a safety net within the team
- "Watching each other's back"
Team members can also use the communication tool known as a Check-back to confirm or question an action or order.
- TeamSTEPPS - I'M SAFE Checklist
Answer I- illness M- medication
S-stress A-Alcohol/drugs F-fatigue E-eating and elimination 3 / 4
- ISMP goals
Answer Goal is to advance patient safety worldwide by empowering the healthcare community, including consumers, to prevent medication errors Collect & analyze reports of near-misses, medication errors, and adverse drug events.
Disseminate current medication safety information and error-prevention strategies to educate HCP and consumers.Advocate the adoption of safe medication standards by accrediting bodies, manu- facturers, policy makers, regulatory agencies, and standards-setting organizations. Conduct research to provide evidence-based safe medication practices.
- Effects of Safety Regulations/Guidelines
Answer Policy changes
- Institutional
- Regulatory bodies
- Do Not Use abbreviations • ISMP
- Safe medication administration guidelines
• Bar code scanning • Safety huddles
• The Joint Commission (TJC)
- human error
Answer Predictable
- Occurs with lapse in personal behavior
- Need to understand how mistakes are made to prevent &
- Need to understand how mistakes are made to prevent and probability of error
- Human and system factors
- / 4
Answer Refers to the study of human behavior, abilities, limitations, and other characteristics as they affect the design and smooth operation of equipment, systems, jobs, and work environment (AHRQ)