N 340 Women's Health & Illness in The Expanding Family & N345 Clinical Practicum

Quality and Safety Education in Nursing

Note: QI Fishbone Diagram assignments are at the bottom of this page! Links for the fishbone templates are right below the swiss cheese models (who knew this course was about food!!)

Why Quality and Safety Education in Nursing (QSEN):

It is imperative that nursing students, new graduates, instructors and nurses have a comprehensive understanding of how quality and safety issues affect patient outcomes . Nursing education focuses on the six areas listed below. Nurses already working in areas such as hospitals, clinics, home care, hospice and community health will know this as Quality Improvement (QI).

Initial steps to providing safe care and creating a safe environment for us to practice nursing include understanding our roles as individual nurses, as part of a nursing team, as part of a unit, as part of a hospital and as part of a health care system. We contribute to both the problems and solutions to patient healthcare! The focus for Quality Improvement and QSEN is looking beyond the care provided by one nurse for one patient. Mistakes and solutions rarely occur as isolated incidences.

Background:

In 1999 the Institute of Medicine (IOM) published shocking results about healthcare errors in the the book: To Err is Human. From this they developed a list of "never events" (such as amputating the wrong leg or a lethal medication error). Much of the information focuses on the hospital setting. The fundamental difference between their findings and recommendations and those of other institutions is the focus on system wide problems. Most errors are system wide and the usual pattern of blame has been to single out one person who "caused" the error. Individuals certainly make errors through being sloppy, cutting corners and because of a lack of knowledge and skills. These tend to be isolated incidences. Though not to be ignored, they usually represent a system wide problem such as working faster (think 5 patients with complex needs!), not receiving proper training in say inserting inserting PICC lines or a system that relies on memory for knowing drug-drug interactions. From the IOM findings, they identified a Culture of Safety.

The Six Areas Include:

These areas obviously are interrelated! Problems and solutions result from us understanding how each of the areas uniquely contributes to our understanding of how problems and solutions occur as well as developing an appreciation for the synergistic effect of all six! From: Cronenwett L; Sherwood G; Gelmon SB; Nursing Outlook, 2009 Nov-Dec; 57 (6): 304-12

AHRQ Safety Culture

Safety culture and culture of safety are frequently encountered terms referring to a commitment to safety that permeates all levels of an organization, from frontline personnel to executive management. More specifically, "safety culture" calls up a number of features identified in studies of high reliability organizations, organizations outside of health care with exemplary performance with respect to safety. These features include:

A Culture of Safety: How to minimize risk of harm to patients and providers through both system effectiveness and individual performance. Ponder solutions related to errors and prudent patient care!

• acknowledgment of the high-risk, error-prone nature of an organization’s activities
• a blame-free environment where individuals are able to report errors or close calls without fear of reprimand or punishment
• an expectation of collaboration across ranks to seek solutions to vulnerabilities
• a willingness on the part of the organization to direct resources for addressing safety concerns

AHRQ Patient Safety Key Concepts

AHRQ Glossary of patient safety terms

The Swiss Cheese Models

How does an error occur? Latent Failure (the blunt end): Errors arising from decisions that affect organizational policies, procedures and allocation of resources. Also included are management, organizational culture, protocols/policies, transfer of knowledge Active failure (the sharp end): Errors arising from direct contact with the patient (i.e. memory failures, attentional failures, competing demands, fatigue).

How is an error avoided (a near miss)? Organization: Safety is a priority. Teamwork, patient involvement, transparency and accountability are key. Individual (i.e. Nurse): Decrease dependence on memory and vigilance. Avoid Vigilance: checklists, well-designed alarms, rested Avoid Memory: Standardizing and simplifying procedures and tasks. Plan and problem-solve!

Ponder: Factors Contributing to the Problem: (Use to fill in the Fishbone Problem Diagram), When you are pondering the problem think about the individual, the system and a combination of factors. Remember to bold the items(s) you believe are key. It works best to start with the Processes box.

• Equipment (design, availability and maintenance)
• Environment (staffing levels and skills, workload and shift patterns, administrative and managerial support, physical space)
• Processes: As the problem was developing, when were key factors occurring?
• Management/Organization: (financial resources and constraints, organizational structure, policy standards and goals, safety culture and priorities)
• Regulation: (economic and regulatory situation, availability and use of protocols, availability and accuracy of tests)
• People/Teamwork: (knowledge and skills/training, competence, physical and mental health, verbal and written communication, supervision and assistance)

Ponder: Solution: What can be done to keep it from happening again? (use to fill in the Fishbone Solution Diagram). When you are pondering the solution think about the individual, the system and a combination of factors.

• Standardize/Simplify/Make Protocol Automation/Computerize
• Education/Training
• Improve or Change Devices/Equipment
• Communication
• Other (Describe)

Use the 6 areas of competencies: Patient Centered Care, Teamwork and Collaboration, Evidence-Based Practice, Quality, Improvement, Safety and Informatics.

Complex Adaptive Systems:

Complex Adaptive Systems (CAS) are different from traditional, mechanistic viewpoints. In CAS problems are not viewed as linear or dependent on hierarchal structures to solve them. It is about multiple levels of situations that are effecting what is going on right now.

Complex implies: -Diversity -Many elements -Large number of connections Adaptive implies: -Capacity to alter or change System implies: -Multiple agents -Agents are interdependent and connected   Is the problem Simple, Complicated or Complex? 1. Simple: one can follow a basic plan of care. Successful resolution is likely when predetermined step are followed. 2. Complicated: More situations are occurring requiring protocols and policies. Complicated problems are made up of subsets of simple problems, but can't be broken down to the individual simple problems. 3. Complex: Expertise is required. Depending on protocols or policies alone are won't work. These are balanced with expertise. The problems are unique. Outcomes are not predictable and solutions can not be assured through known formulas of care. Lindberg, C, Nash, S. & Lindberg, C. (2008). On the edge: Nursing in the age of complexity. Bordentown, New Jersey: Plexus press

The aims of a CAS are:

• Understand and explain the behavior and dynamics of systems composed of many interacting elements.
• Uncover the principles and processes that explain how order and change emerge in these dynamic, non-linear systems.

Properties of a CAS:

• Distributed Control: In a CAS control is shared by many elements, rather than centralized in a single command center.
• Coexistence of Order and Disorder: In a healthy adaptive system, order and disorder coexist
• CAS are Nonlinear: a small change may produce a large effect, or a large change may produce a small or no effect.
• Inability to Predict: Outcomes are unpredictable.
• Emergence: In a CAS outcomes emerge through a process of Self-Organization rather than through centrally planned or directed processes.
• Self organization: the ability of a CAS (let's say a hospital unit) to adapt and change during both emergent and long term changes.

CAS are about the relationships among People/Teamwork, Processes, Management/Organization, Equipment, Environment and Regulation. They are not about the people and things themselves. The idea is to uncover the principles and processes that explain how order and change emerge in these dynamic, non-linear systems.

Quality Improvement Project

Instructions:

• Read the Information above on QSEN and Complex Adaptive Systems
• Choose a problem related to a patient care problem you became aware of during this clinical. In the Moodle Discussion message box, provide us with a brief summary of the problem (enough so we can put the Fishbone diagrams in context!). There is an example at the bottom of this page.
• Complete the Fishbone Problem Diagram and Fishbone Solution Diagram Using these diagrams as a concise way of identifying aspects of your problem and proposed solution. In the solution text box clearly state the solution.
• Include at least one item in each of the six categories (i.e. People, Processes, etc). These will be a combination of latent and active failures (see swiss cheese model below). Discuss with your preceptor and other nurses as seems appropriate. Bold the one or two items you believe are key to the problem and then to the solution.
• Use EBP: Obtain input from your clinical experience, the literature, existing protocols! In the problem and solution text boxes clearly state the problem and the solution. Describe why it is a complex problem. Cite at least one evidence based practice article.
• Include at least one item in each of the six categories (i.e. People, Processes, etc). These will be a combination of latent and active failures (see swiss cheese model above). Discuss with your preceptor and other nurses as seems appropriate.
• Post in Quality Improvement Discussion Forum. In the discussion box, let us know specific feedback you want. Attach your Fishbone Problem and Solution Diagrams.

Example of a problem statement: Yesterday a mother came in, birthed normally, was transferred to the postpartum unit and very soon afterwards started to hemorrhage. Her IV had been removed before she came over from L&D.The patient was stable upon admission to the PP unit. However within 1/2 hour her uterus was boggy and she was bleeding a lot. She had Methergine and Cytotec ordered. The nurse elected to not give Methergine initially because the women's BP was 140/94. There was not the correct dose of Cytotec in the Pyxis and so this was not given initially. The patient hemorrhaged in front of her husband, became comatose and developed DIC in a matter of 20 minutes. The rapid response team was called, but went to L&D first as they had never been to the Postpartum Unit. The patient is now intubated up in the ICU. Her newborn is in the normal nursery here. How might the Problem Fishbone look?

QI Fishbone Problem and Solution Diagrams: Remember this is related to a patient care problem you identified in clinical

Here is an example of a well done Problem diagram (though not perfect!). Note: the key issues are not bolded as you are instructed to do. The EBP article example was in cited in the dialogue box and does not appear on the actually diagram).

Here is an example of a well done Solution diagram (though not perfect!). Note: the key issues are not bolded as you are instructed to do. The EBP article example was in cited in the dialogue box and does not appear on the actually diagram).