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Current "World of Healthcare": Our Patients and Families
Sicker, More Complex
Older
Higher Expectations
More informed, assertive
Increased Co-Payments and Denials/Decrease access
Decrease in Public Trust
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Current "World of Healthcare": Our Work Environment
- Increase Nurse:Patient ratio
- Frequent Interruptions
- More technologically advanced
- Shortages in workforce
- Increase productivity ("do more with less")
- Litigious society
- Multitude of Regulations
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One who initiates a lawsuit seeking compensation for damages (ie: patient)
Plaintiff
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Party against who a suit is brought demanding compensation (ie: hospital)
Defendant
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Professional misconduct...failure to meet the standard of care of a profession which resulted in harm to another
Malpractice
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Failure to exercise due care resulting in harm or injury to another party
Negligence
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Amount of money a court orders a defendant to pay the plaintiff
Damages
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Laws that specify the length of theme within which a person may file specific types of lawsuits
Statue of Limitations
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"Let the master answer"...legal doctrine that makes an employer responsible for consequences of the acts of a servant of employee while acting within the scope of employment
Respondeat Superior
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Def of Standard of Care
A reasonably prudent person with similar training and expertise would exercise under the same or similar circumstances
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Nurses and Physicians operate under ____ standards of care
National
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Hospitals operate under ___ standards of care
Community (locality rule)
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Medical malpractice is based on ____
standard of care
(ie: how would a reasonably competent nurse conduct themselves with regard to skills, knowledge and degree of caring in a similar situation)
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Sources of Standard of Care:
- State nurse practice acts
- American Nursing Association (ANA)
- ASPAN, AORN
- Joint Commission
- Case Law and Published Opinions by Judges
- State Statutes and administrative Codes
- Hospital Policies
- Authoritative Nursing Texts and Journals
- Locality Rule/Community Standard
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IOM Report: To Err is Human
44-98,000 people die in the hospital each year due to medical errors
Events related to medical errors are the 3rd leading cause of death in the US after heart disease and cancer
Errors are caused by faulty systems and processes, NOT people
Healthcare professionals pay with loss of morale and frustration at not being able to provide the best care possible
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6 Aims of Improvement for Healthcare (IOM March 2011)
- Safe
- Effective
- Patient-centered
- Timely
- Efficient
- Equitable
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Average ICU pt experiences ___ errors per day
2 errors
(this equates to 2 dangerous landings per day and 32,000 checks deducted from the wrong account per hour)
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In order to assert negligence, one must prove all of the following:
- Duty owed
- Breach of Duty
- Proximate cause
- Injury or Damages
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Reasons why professionals are sued:
Failure to assess the pt and take adequate history
Failure to observe and monitor the patient
Failure to perform a procedure properly
- Failure to supervise patients resulting in a fallFailure to perform or communicate information to the physician
Failure to follow a physician's order promptly and correctly
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Ways to supervise patients and prevent falls:
Check patient every 2 hours or more for toilet needs
Visually check the patient every hour
Chart your observations, time your entry!
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How to protect yourself from being sued:
Good nurse/patient relationship
Listen to your patient and family
Ask for help when you are not sure or overwhelmed
Good documentation
Good communication
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Things TO put in the patient chart:
Patient behavior (especially noncompliant)
Quotes
Neat, Legible entries
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Things NOT to do when charting:
- Advertise of incident reports
- Try to settle disputes or assign blame
- Keep secrets
- Don't get personal
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10 Basic Charting Guidelines:
Time, Date and Sign all entries
Write legibly in ink
Use only hospital approved standard abbreviations
Be concise and complete
Be specific and objective
Display thought processes
Make all entries promptly
Make continuous entries
Make certain entries are consistent and avoid contradictions
Make alterations carefully
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According to Documentation in the EMR..."If it is not written down....."
It never happened
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Documenting Medical Errors: DON'Ts
Point fingers at others
Use words like "accidentally", "regrettably", or "too busy"
Not referring to incident report or risk management
Not airing concerns about workload or staffing
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Documenting Medical Erros: DOs
Keep it factual and objective
Chart your actions, what was ordered, what was given and patient response
Remember your charting is your best defense
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Freedom from accidental injury or risk of harm
Safety
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The work of patient safety is to:
- Reduce or mitigate harm
- Improve health outcomes
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Safety requires:
- knowledge
- trust
- system re-design
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Patient safety requires understanding of:
- Safety as a system
- People are fallible
- There is a body of knowledge and experience to draw from
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On average, there are ___ sentinel events per hospital per year (mostly never reported)
10-20
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Any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
Sentinel Event
(serious injury specifically including loss of limbs or function)
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The phrase "or risk thereof" includes any:
process variation for which a recurrence would carry a significant chance of a serious adverse outcome
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Types of Sentinel Events:
(any unanticipated death not related to the natural course of the patient's illness or underlying condition; suicide of patient; major permanent loss of limb or function not related to the natural course of the patient's illness or underlying condition)
Infant abduction
Infant discharged to wrong patient
Rape by another patient or staff
Hemolytic transfusion reaction involving administration of blood or blood products having a major blood group incompatibilites
Surgery on wrong patient or body part
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Root cause of Sentinel Events
Communication
(hand-offs prime time for communication breakdown...reconciliation of medications)
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Purpose of group: Root Cause Analysis
To conduct an interdisciplinary review of an unexpected patient outcome in order to improve the patient care we provide
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Root Cause Analysis IS:
Collaborative
Oriented toward system and process improvements
Incorporates information from a variety of different sources
Action oriented
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How is an ethics consult done:
- Date/Time Consult
- -give reason for the consult and who requested it
- -brief synopsis of the patient's overall condition
- -discussion with pt if possible, family, attending physician, and staff
- -if patient is unable to communicate always ask if there is an advance directive or what the patient expressed to the family
- Give opinion using the frameworks for Ethical Analysis
- Document appreciation for the consult and make sure the attending physician knows the opinion
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Essentials that MUST be documented:
- Assessments
- Converstations
- PT interactions (use quotes)
- Family interaction
- Risks/Informed Consent
- Orders
- Non-Compliance
- Instructions to patient
- Changes in condition
- Time/Date and Sign all entries
- Write legibly in Ink
- Only hospital approved abbreviations
- Concise and complete
- Specific and Objective
- Display though processes
- Make all entries promptly
- Make continuous entries
- Make sure entries are consistent and avoid contradictions
- Make alterations carefully
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Common causes of medication errors:
- Failed communication
- Poor drug distribution practices
- Dose miscalculations
- Drug- and drug device-related problems
- Incorrect drug administration
- Lack of patient education
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STAR system
***use when giving high risk drugs or are distracted/hurry
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Guidelines for Reducing Potential Liability Claims:
Know applicable state statutes pertaining to nursing practice and comply with them
Encourage open communication with patients
Always chart completely and objectively, avoiding conclusive and subjective statements
NEVER enter into chart wars with coworkers or physicians....Medical records are not the place to air your grievances
Know the proper chain of command when encountering a problem with a physician's treatment of a patient
- Never speak with an attorney about a patient without informing Risk Management
- (Questionable inquiries from persons outside the hospital should be directed to your supervisor or the Risk Manager)
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