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patient safety is
freedom from danger, harm or risk
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safety is whose concern?
evryones
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medical errrors are the _ leading cause of death in the US
6th
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3 types of identifiers are
- NAme
- DOB
- medical number (hosp. assigned)
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DO NOT use these identifiers
- pts room number
- id on confused pt
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what is the leading cause of errors in hospital
Communication break down
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how do you improve effective communication
- repeat/verify orders
- use standard abbrev
- timely report of critical test/lab
- use a reporting guide
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ISBARR
- mnemonic to organize info to doc
- identify
- situation
- background
- assessment
- recommendation
- repeat order back
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med error reporting =
- asses pt, vs, LOC, labs
- assess for effect of meds
- cotact Dr
- paperwork
- monitor pt
- how do you prevent this in future
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what info do you give for pt education for med
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it is the nurses job to
medicatio reconcilliation
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med reconciliation should be done when
- admission
- status change
- transfers
- discharge
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who is at risk for falls in hospitals
EVERYONE
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how do you reduce the risk of harm from falls
assess everyone for fall risk
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risk factors for fall
- orthostatic hypotension
- previous fall risk history
- MS
- ability to ambulate
- sensory impairment
- age
- equipment attached to
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where do you id a fall risk
- on pt door
- chart
- and arm band
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get up and go test
- how well do they stand from a chair
- do they need assistance getting up
- assess gait
- can they control decent back into the chair
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interventions to decrease fall risk
- Keep bed in low position
- Place call light in reach at all times
- Answer call lights promptly
- Keep room free of clutter
- Keep bed/wheelchair in locked position
- Use proper lift equipment
- Assist patients to the bathroom regularly
- Use a gait belt when ambulating pts.
- Use non-skid foot wear when getting patients out of bed
- Keep urinal, water pitcher, glasses, and personal belongings in reach
- Ensure appropriate lighting
- Use Safety Monitoring Device for patients with confusion
- Raise 2-3 ½ length side rails
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can you put up 4 side rails
- no only three
- 4 is a restraint
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what to do in incident report
- assess pt
- make judgemnt about if you can get pt up
- call physician
- incident report
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can you report that pt fell if you dont see them
- NO
- you can only chart what you can see
- yo can say heard pt yell then heard bang and saw pt on floor
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FIRE SAFETY RACE =
- R- rescue and remove all pt in immediate danger
- A- activate fire alarm
- C- contain the fire , close doors, windows, turn O2 and electrical equipment off
- E- evacuate pt and others to a safe area/extinguish the fire if trained to do so
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QSEN =
- quality and safety education for nurses
- prepare future nurses to improve pt safety
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6 QSEN
- pt centered care
- teamwork and collaboration
- evidence based practice
- quality improvement
- safety
- informatics
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what is the key to prevent errors
communication
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what things can attribute to human error
- inattention
- distractions
- failure to communicate
- poor equipment design
- exhaustion
- ignorance
- noisy conditions
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what are sentinel events
an unexpected occurence involving death or serious physical or psychological injury, or the risk thereof
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RCA =
- root cause analysis
- a process for identifyig the basic or casual factors that underlie variation in performance, including the occurence or possible occurence of a sentinel event
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how do you develop pt centered care =
- encourage pt family to be involved
- ask question and educate them
- listen to familys concerns
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FMEA =
- failure modes and effects analysis
- a systemic eval of a process and a look at each step to see wher it can fail
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