Transcript: P S Risk Assessment Leadership Assertive - speaking up - “I need clarity” Structured communication Read backs – provides clarification & accuracy of verbal orders Time-outs – before an invasive procedure, to ensure correct procedure, at correct body site, correct patient Hand-off – Information is transferred as cohesive plan between shifts, departments, and units Create a worklife and physical environment that supports the safe delivery of care and service Patient Safety Worklife/ Workforce Briefings – short discussions at the BEGINNING of procedures Debriefing – at the END of a procedure to allow for review Just Teamwork Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum Communication Annie’s Story Article: Learns from mistakes (medical errors, near misses) Seeks new opportunities for performance improvement Evaluation of learning process Learning culture celebrates rewards success Teamwork activity in groups Incorporating best practices and standardization may be leaderships gretest challenge to developing safety culture – shift from the art of medicine Use evidence to create standards of practice Learning Client flow Client safety: education and training Client safety plan Preventive maintenance program Workplace violence prevention Views patient and family = hospital existence Care and compassion Empowers patients to be apart of their care decisions Ultimately will lead to safety actions References Hand-hygiene compliance Hand-hygiene education and training Infection rates Pneumococcal vaccine Reprocessing ACTIVITY TIME Falls prevention strategy Home safety risk assessment Pressure ulcer prevention Skin and wound care Suicide prevention Venous thromboembolism (VTE) prophylaxis Evidence Based Was the care provider’s behavior malicious? Was the care provider under influence of alcohol or drugs? Was the care provider aware he/she was making a mistake? Would two or three of the care provider’s peers make the same mistake? Nursing leaders need to carefully assess the safety culture in their workplace Use a framework to guide personnel in order to increase safety within their work settings http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html Recognizes errors as SYSTEM FAILURES rather than individual failures Characterized by trust Non-punitive Blame-free error-reporting atmosphere A multidisciplinary and multigenerational approach crossing all ranks, layers and individuals across an organization Infection Control Communication Ensure safety use of high risk medications Activity: print out this to each group (yes or no questions) – show a scenario?? Medication Use Sammer, C., & James, B. (2011). Patient safety culture: the nursing unit leader’s role. The Online Journal of Issues in Nursing, 16(3). doi: 10.3912/OJIN.Vol16No03Man03 Sammer, C., Lykjens, K., Singh, K., Manins, D., & Lackan, N. (2010). What is Patient Safety Culture? A Review of the Literature. Journal of Nursing Scholarship, 42 (2), 156–165. Other Forms of Communication Client and family role in safety Dangerous abbreviations Information transfer Medication reconciliation as a strategic priority Medication reconciliation at care transitions Safe surgery checklist Two client identifiers Just Antimicrobial stewardship Concentrated electrolytes Heparin safety High-alert medications Infusion pumps training Medication concentrations Narcotics safety GAME :) Reduce the risk of health care-associated infections and their impact across the continuum of care/service Identify safety risks inherent in the client population Patient Safety
Transcript: Goal 14: Prevent Health care-associated pressure ulcers (decubitus ulcers). NPSG. 14.01.01: Assess and periodically reassess each patient TIP FOR SUCCESS: Effective Plan to Prevent Pressure Ulcers: 1. Recognizing at risk individuals 2. Reducing the incidence of pressure ulcers through education programs. 3. Maintaining and improving tissue tolerance to pressure to prevent injury 4. Protecting against the adverse effects of external mechanical forces 5. Meeting the patient’s nutritional supports needs 6. Identifying a prevention program Preventing Pressure Ulcers Goal 15: The Organization identifies risks inherent in patient population. To make sure patients are safe from harm, staff should do the following: NPSG 15.02.01: Identify risks associated with home oxygen therapy such as home fires. (Home Care) Homes where supplemental oxygen is in use should have the following Thank YOu ^_^ The use of clinical practice guidelines Karen Gay D.T. Cruz RN Patient safety NPSG. 15.01.01: Identify patient at risk for suicide.
Transcript: Prisoners have a higher level of chronic disease than the general population (Butler, Kariminia et al. 2004) Health professionals have to work in an environment where healthcare may not always be the common predominant concern. Concentration on mental health disorders rather than physical health problems. At her majesty's pleasure Mr P was unable to administer any insulin for 2 days. 60 Mr P's wife and son visit on Easter Sunday. They realise he is very confused and seriously unwell. Mr P is taken to hospital, and is under 24/7 direct observation by 2 prison guards. 76 year old with implanted pacemaker Insulin dependent diabetic Began experiencing confusion and SOB Bed-bound for 48 hours In terms of healthcare, are our prisons safe? The Stats Mr P was diagnosed with infective endocarditis. The infection was thought to have been introduced when his pacemaker was replaced. He spent 1 month in JCUH, then was discharged back to prison to serve the remaining 14 weeks of his sentence. Of all 138 UK prisons, 17 do not keep a record of which prisoners are diabetic. 38 prisons do not have written guidelines for the management of diabetes. 66 prisons held no specific diabetes clinics for inmates. 36 prisons had no system in place to transfer prisoners' GP records from the community to the prison. Mr P Healthcare in UK Prisons Patient Safety Is it fair to allocate more funding and time to psychiatric healthcare rather than care for chronic diseases? ECG BPM Provided by private companies contracted by NHS since 2005. Aims to provide the same standard of healthcare available outside of prison. Prison doctors must approve all treatment. Few doctors for many patients - is this safe? When someone with a chronic disease is sentenced, are they likely to suffer unnecessarily?
Transcript: At the moment the hospital and staff is the only source of support he has. Winter +COPD + the street = Re-admission Do nothing? Anon. Nurse Thank You! Move to a base sight? The Dillema The dangers of Discharge "This is Not a Bl***y B&B" Lack of Care and Support The risk of another exacerbation. 55 Year old male recently recovered from exacerbation of COPD, spent 1 week in ICU In relation to his illness he is fit for discharge But he is...... For his own safety he should stay... The Scene What Would You You do? Hospital aquired infections Taking up a bed in NSECH Patient Safety For his own safety and that of others he should go.... Discharge him there and then? 62 ECG bpm
Transcript: Attributes of a patient-centred team Outcomes Multidisciplinary pain management EMPATHISE ENGAGE Outcomes for Mrs Brown Pain influences and inhibits numerous areas of a patient’s life and reduces its quality Chronic pain requires an integrated, multidisciplinary team with the patient at the centre Reference: Chief Medical Officer's report 2009 Diagnosed with rheumatoid arthritis in 2005 Previously admitted to hospital with fractured left proximal humerus Currently taking methotrexate and NSAIDs to deal with chronic pain Increase in quality of life Increase in satisfaction of standard of care (Swenson 2004) Shown to reduce perception of pain (Sarinopoulos 2013) Enhanced communication (Ahmed 2011) Increase in compliance (Jacobson 2009) Outcomes for the team EDUCATE References Increase in 'collective efficacy', 'team maturity' and 'negotiated space' (Howarth 2012) Increase in job satisfaction (Jensen 2011) Reduces physical workload (Jensen 2011) Increase in quality of care (Bleet 2010) Patient-centred communication in multidisciplinary pain management ENLIST Tongue 2005 Case History Mrs Brown 72 years old Enjoys gardening and looking after her grandchildren Husband recently passed away
Transcript: 7 Driving Factors for Patient Safety 1) Leadership 2) Evidence Based Practice 3) Teamwork 4) Communication 5) Learning 6) Just - acting on what is morally right and fair 7) Patient-centered Culture Why Hospitals Should Fly by John Nance NCLEX Question References What is your role: Where do we go from here? What is driving Patient Safety? Safety starts at all levels To help implement and keep policies in line To Inspire those you work with To take action during acute situations that require innovations To teach new hires or students Nance, J. J. (2008). Why hospitals should fly: The ultimate flight plan to patient safety and quality care. Bozeman, Mt.: Second River Healthcare Press. Paranda, A. (2014, September 5). The role of hospital managers in quality and patient safety: A systematic review. Retrieved from http://bmjopen.bmj.com/content/4/9/e005055.full Mitchell, P. H. (2008, April). Defining Patient Safety and Quality Care. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2681/ Patient Safety Network. (2015, March). Nursing and Patient Safety. Retrieved from https://psnet.ahrq.gov/primers/primer/22/nursing-and-patient-safety Sammer, C., James, B., (September 30, 2011) "Patient Safety Culture: The Nursing Unit Leader’s Role" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 3, Manuscript 3. Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-16-2011/No3-Sept-2011/Patient-Safety-Culture-and-Nursing-Unit-Leader.html The Joint Commission. (2016). Hospital national patient safety goals. Retrieved from http://www.jointcommission.org/assets/1/6/2016_NPSG_HAP_ER.pdf "A change in culture requires a change in mindset" National Patient Safety Goals 2016 Nurse to patient Ratio Nursing skill mix and training Nurse burnout Long shifts with overtime Disruptive and unprofessional behavior from staff A student nurse is taking care of a patient. Which action would require the RN to intervene in order to prevent the compromise of patient safety? (Select all that apply) a) The student nurse attempts to start an indwelling catheter using sterile technique b) Pushes IV Adenosine slowly c) Hangs IV medication and starts it on the IV pump without undoing the roler clamp d) Cleans the top of medication vial with an alcohol swab prior to administing injection e) Charts medication administation in computer system 2 hours after it was actually administered Identify patients correctly Improve staff communication Use medicine safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery Latent failure Active failure Organizational system failure Technical failure "To Err is Human" How WE compromise patient safety Patient Safety: the prevention of harm to patients
Transcript: Example of a Jeopardy Template By: Laken Feeser and Rachel Chapman When creating without a template... http://www.edtechnetwork.com/powerpoint.html https://www.thebalance.com/free-family-feud-powerpoint-templates-1358184 Example of a Deal or No Deal Template PowerPoint Game Templates There are free templates for games such as jeopardy, wheel of fortune, and cash cab that can be downloaded online. However, some templates may cost more money depending on the complexity of the game. Classroom Games that Make Test Review and Memorization Fun! (n.d.). Retrieved February 17, 2017, from http://people.uncw.edu/ertzbergerj/msgames.htm Fisher, S. (n.d.). Customize a PowerPoint Game for Your Class with These Free Templates. Retrieved February 17, 2017, from https://www.thebalance.com/free-powerpoint-games-for-teachers-1358169 1. Users will begin with a lot of slides all with the same basic graphic design. 2. The, decide and create a series of questions that are to be asked during the game. 3. By hyper linking certain answers to different slides, the game jumps from slide to slide while playing the game. 4. This kind of setup is normally seen as a simple quiz show game. Example of a Wheel of Fortune Template https://www.teacherspayteachers.com/Product/Wheel-of-Riches-PowerPoint-Template-Plays-Just-Like-Wheel-of-Fortune-383606 Games can be made in order to make a fun and easy way to learn. Popular game templates include: Family Feud Millionaire Jeopardy and other quiz shows. http://www.free-power-point-templates.com/deal-powerpoint-template/ Quick video on template "Millionaire" PowerPoint Games Some games are easier to make compared to others If users are unsure whether or not downloading certain templates is safe, you can actually make your own game by just simply using PowerPoint. add logo here References Example of a Family Feud Template PowerPoint Games are a great way to introduce new concepts and ideas You can create a fun, competitive atmosphere with the use of different templates You can change and rearrange information to correlate with the topic or idea being discussed. Great with students, workers, family, etc. For example: With games like Jeopardy and Family Feud, players can pick practically any answers. The person who is running the game will have to have all of the answers in order to determine if players are correct or not. However, with a game like Who Wants to be a Millionaire, the players only have a choice between answers, A, B, C, or D. Therefore, when the player decides their answer, the person running the game clicks it, and the game will tell them whether they are right or wrong.
Transcript: Mitchell, P.H. (n.d.) Defining patient safety and quality care. [pdf] Retrieved from: http://ahrq.gov The Institute of Medicine defined patient safety as " the prevention of harm to patients (Mitchell, n.d.) Basic nursing practices to ensure patient safety You as the medical professional hold the key to delivering high quality care ensuring patient's safety. Patient safety Are you doing your part to ensure your patient's safety?!?!? Back to the Basics *Use of propholaxis of DVT's in those at risk *Use of perioperative beta-blockers in appropriate patients to prevent perioperative mortality and morbidty. *Use of maximun sterile barriers while placing central venous catheters to prevent infections. -Bed rails up x3 -Call light within reach -Bed locked in lowest position -Check patient identifiers prior to medication administration Patient safety practices
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