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bundle
A combination of patient care elements that can be consistently implemented to reduce harm
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Centers for Medicare and Medicaid Services
CMS - A federal organization that pays for healthcare for low-income and elderly people and tracks healthcare outcomes
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incident report
A report filed that documents an accident or injury occurring in the hospital
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Institute for Healthcare Improvement
An organization that focuses on safety of patients and that has developed a number of bundles of care to achieve that goal
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Institute of Medicine
A professional organization that has identified six aims of 21st century healthcare: that all healthcare should be safe, effective, patient-centered, timely, efficient, and equitable
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Patient-centered care
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
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Teamwork and collaboration
Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.
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EBP
Evidence-based practice - Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.
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QI
Quality improvement - Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.
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Safety
Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
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Informatics
Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
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healthcare
that all healthcare should be safe, effective, patient-centered, timely, efficient, and equitable
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just culture
An approach to error evaluation that examines the nature of the error to assist in determining the appropriate response to the individual who made the error
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quality
The excellence or superiority of something; often viewed on a continuum, from poor quality to high quality
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Quality and Safety Education for Nurses
A project designed to provide a framework for the knowledge, skills, and attitudes necessary for future nurses
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root cause analysis
RCA - A process used to determine the underlying cause of an event. Asking why 5 times.
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safety
The avoidance or prevention of adverse outcomes for patients
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safety science
The study of safety knowledge and technology to prevent harm to patients
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sentinel event
Safety error in which hospitals are required to report serious safety events to regulatory agencies and state health agencies
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Tall Man Letters
Medications with similar names may lead to administration errors. The Institute for Safe Medication Practices (ISMP) has advocated a system of using capitalized letters within a drug name to differentiate drugs with similar names.
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CLABSI
- Care bundle: central line–associated bloodstream infection. 5 elements:
- -Hand hygiene
- -Maximal barrier precautions during insertion of the line (sterile gown and gloves, cap, face shield, sterile drape)
- -Preparation of skin at insertion site with chlorhexidine
- -Optimal catheter site selection, avoiding the femoral vein site in adults
- -Daily review of line necessity with prompt removal when no longer needed
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Value-Based Purchasing
VBP - CMS adjusts hospital reimbursement based on adherence to guidelines for processes and outcomes of care and patient satisfaction.
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Latent errors
Latent errors are those due to systems issues. The effects of latent errors may be apparent immediately and may certainly cause significant harm to patients.
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