7 The correct response is: A, B, C, D, EIdentify areas of patient safety strengths—Correct. It is important to recognize and celebrate areas of strength.Increase staff awareness about patient safety—Correct. Administering the survey helps to reinforce the importance of safety in the minds of nurses and other members of the interprofessional team.Highlight areas of opportunity for patient safety culture improvement—Correct. The survey helps to identify where effort is needed to improve safety.Examine trends in patient safety culture over time—Correct. It's important to track changes in the culture of safety over time.Evaluate the impact of specific interventions—Correct. As the organization implements safety initiatives, the survey can be used to measure changes.
8 The correct response is: A, B, D, F, GRationale:Transformational leadership—Correct. This is one of the five key components of the Magnet® model.Exemplary Professional Practice—Correct. This is one of the five key components of the Magnet® model.Information Technology—No. This is one of the six QSEN competencies for nurses. While this is important to Magnet®, it is subsumed under New Knowledge, Innovations and Improvements.Structural Empowerment—Correct. This is one of the five key components of the Magnet® model.Teamwork and Collaboration—No. This is one of the six QSEN competencies for nurses. While this is important to Magnet®, it is subsumed under Exemplary Practice.New Knowledge, Innovations and Improvements– Correct. This is one of the five key components of the Magnet® model.Empirical outcomes—Correct. This is one of the five key components of the Magnet® model.
9 The correct response is: BRationale:Plan‐Develop‐Start‐Act—NoPlan‐Do‐Study‐Act—Correct. PDSA means plan‐do‐study‐act. Some people refer to it as “plan‐do‐check‐act” instead.Prepare‐Do‐Select‐Acquire—NoPrepare‐Develop‐Stop‐Ask—No
10 The correct response is: A, C, DRationale:Value‐based purchasing—Correct. This program rewards hospitals based on safety, quality, patient experience, and financial performance.Hospital report card act—No. The Hospital Report Care Act is a state program that provides consumers access to information about the quality of health care in their state.Hospital readmission reduction penalty—Correct. This program penalizes the hospital if its actual readmission rate for patients with six conditions is higher than expected readmissions adjusted for patient comorbidities.Hospital‐acquired conditions reduction—Correct. This program examines safety indicators and hospital‐acquired infections and penalizes poor performing hospitals.
REVIEW ACTIVITIES
1 Review the mission, vision, and values of a health care organization, either at the facility or on the facility's website. How do the documents address concern for high reliability and patient safety?
2 While you're at a health care facility, ask a nurse to describe the process in place to report an error, and what happens when an error is reported. Based on what you've learned, is the reporting method focused on learning or blame?
3 Leaders are responsible for creating a culture of high reliability. Review the QSEN competencies outlined in this chapter. During your next clinical rotations, assess the culture of the health care organization. Are the leaders visibly committed to safety? Are nurses involved in process improvements? Is technology used to enhance safety?
4 Review the chapter content related to the Science of Human Error. Why is it important to know if the error is skill‐based, rule‐based, or knowledge‐based? Which types of errors have you made, in your personal or professional life? What tools would help prevent these errors?
5 Review the chapter content related to the I PASS the BATON and SBAR communication tools. The next time you are providing care, try using one of these tools in your handoff to another provider. Did the tool help you to organize your thoughts more concisely? Did it prompt you to share the most pertinent information?
6 The government and other organizations are mandating public reporting for health care safety, quality, and financial indicators. How does this transparency influence quality and safety? What nursing resources are available to assist a health care organization on the road to high reliability? What interprofessional resources are available?
DISCUSSION POINTS
1 During your last clinical experience, how was quality nursing care visible?
2 What types of quality initiatives were visible on the nursing unit?
3 What quality improvement models were used in the institution?
4 How does the culture of a hospital affect nurse involvement with quality improvement projects?
5 How can you improve quality and safety as a direct care nurse?
DISCUSSION OF OPENING SCENARIO
1 What factors may have contributed to the original error?
2 Why was an interprofessional team convened for the root cause analysis?
3 What factors may have contributed to a second error in the pediatric department?
4 Both human factors and organizational factors may have contributed to this error. The nurse may have been fatigued or rushed. She may not have treated the breast milk like a medication, and may not have checked the table three times. The nurse may have experienced confirmation bias, seeing what she expected to see. The nurse may have read the label correctly but reached for the wrong container. The label may have been handwritten and difficult to read. The room may have been poorly lit, making it difficult to read the label. Breast milk storage may not have been individualized for each patient, making it easy to grab the wrong container. The organization may not have invested in bar code scanning technology.
5 Although on the surface this appears to be a simple nursing error, as seen above, many factors may have contributed to the error. All stakeholders should be involved in a root cause analysis to provide a broad perspective and create the most effective plan for preventing the error in the future.
6 Organizational culture, communication, and human factors may allow the same error to occur in different areas within the same organization. If an organization lacks transparency, lessons learned from errors in one area are not shared with other areas. They are kept “secret.” Even if an organization aspires to transparency, communication must be clear, concise, and targeted so that the information is received and perceived to be important by the clinicians who may be affected. Nurses and other clinicians must realize they, too, are vulnerable to making errors. The attitude of “I would never make that mistake” needs to be expunged.
EXPLORING THE WEB
1 www.ahrq.gov, to review an Agency for Healthcare Improvement Patient Safety Survey tool, Accessed August 28, 2019.
2 www.medicare.gov/hospitalcompare/search.html, to compare hospital quality performance, Accessed August 28, 2019.
3 https://ww2.mc.vanderbilt.edu/crew_training for Vanderbilt Crew Training information, Accessed August 28, 2019.
4 http://qsen.org to review QSEN competencies for undergraduate and graduate nurses, Accessed August 28, 2019.
5 https://nursingworld.org to see nursing's position on culture of safety and just culture, Accessed August 28, 2019.
INFORMATICS
Go to the website for the Centers for Medicare and Medicaid Hospital Compare, www.medicare.gov/hospitalcompare/search.html. Accessed August 28, 2019. Enter several hospitals located close to your zip code. Review the ratings. What are their strengths? Where do they have opportunities to improve their safety?