Transcript Patient Safety Advocate

SAFETY
 http://www.youtube.com/watch?v=kg2kEzWIOI&feature=fvwrel
 Quote for the Day:
 It is improper to consider personal danger when the
public welfare is at stake." (Maimonides, "Iggeret Teman")
PATIENT SAFETY
ADVOCATE
Developed by D. Ann Currie, RN,MSN
PATIENT SAFETY
ADVOCATE
 Patient Safety Advocate:
 A licensed nurse who promotes safety in the patient and family
environment by: following scope and standards of nursing
 practice; practicing within the parameters of individual knowledge,
skills, and abilities; identifying and reporting actual and potential
 unsafe practices; and implementing measures to prevent harm. .
RNSG 2308 COURSE
OBJECTIVES
 Unit IV: Patient Safety Advocate

1.
Examine the Texas Nursing Practice Act and the Texas Board of
Nursing Rules that emphasis safety as well as the federal, state, and local
government and accreditation organizations safety requirements and standards in
regard to the maternal, newborn, women’s health care patients. (SLO #4, & 5)
 2.
Identify measures that promote quality patient-centered care and a
safe supportive, protective environment for childbearing families, women
selected health issues, the nurse, and other health care team members.(SLO #4 &
5)
 3.
Examine the nurse’s role in local health facilities and community
regarding disaster planning and bioterrorism as it relates to childbearing families
and women with selected health issues. (SLO #5 & 6)

RNSG 2308 UNIT IV
OBJECTIVES

1.
Discuss the Texas Nursing Practice Act and the Texas Board of Nursing Rules in regard to
safety in the caring of the maternal, newborn, and/or women’s health patients.

2.
Compare and contrast the federal, state, and local government and accreditation
organizations’ safety requirements and standards in the patient-centered nursing care of the maternal,
newborn and women’s health patients.

3.
Examine the policies and procedures of area facilities as they pertain to the delivery of
safe patient-centered nursing care for the childbearing family and women health care patients.

4.
Discuss National Standards for safe Nursing Practices as they apply to the maternal,
newborn, and/or women’s health care patients.
CONT. UNIT OBJECTIVES
 5.
Discuss the principles of quality improvement and outcome measurement in
health care organizations in regard to the maternal, newborn, and/or women health
patients.
 6.
Identify potential risk for maternal, newborn, and/or women’s health patient
harm related to accidents.
 7.
Discuss measures to prevent risk to the maternal, newborn, and/or women’s
health patient resulting from errors and preventable occurrences.
 8.
Summarize national and state standards and guidelines and procedures for
infection control in the maternal, newborn, and/or women’s health care areas.
CONT. UNIT OBJECTIVES
 9.
Discuss the importance of correctly identifying and matching the
mother and infant couplet on the mother baby or postpartum unit.
 10.
Explore the role and responsibilities of the nurse in regard to baby
abduction.
 11.
Discuss the nurse’s role in local facilities and community regarding
disaster planning and preparedness for childbearing families.
 12.
Examine the nurse’s role and responsibilities internal and external
disasters in the maternal, neonatal and women’s health care areas of the hospital.
CONT. UNIT OBJECTIVES

13.
Explain the specific bioterrorism agents (effects of biological, chemical,
and nuclear agents) on reproduction, pregnancy outcomes, fetus, and neonate.

 14.
Compare how the interventions for biological agents differ in pregnant
patients.

 15.
Discuss how the nurse can utilize evidence based nursing practices to
improve the quality and safety of the patient-centered nursing care for childbearing
patients, women with selected health issues and their families.

 16.
Explore the how the use of technology and informatics can assist in the
nurse in delivering safe patient-centered nursing care for childbearing patients, women
with selected health issues and their families.

PATIENT SAFETY –IT CAN
GO WRONG
 http://www.youtube.com/watch?v=BFd54Yzgvo&feature=autoplay&list=PLCBDB95498F3E4649&playnex
t=2
TEXAS
NURSING PRACTICE ACT
AND
TEXAS BOARD OF NURSING
(BON)RULES
THAT
EMPHASIZE SAFETY
 http://www.bne.state.tx.us/
TEXAS DEC’S
 Patient Safety Advocate:
 A. Demonstrate knowledge of the Texas Nursing Practice Act and the Texas Board of
Nursing Rules that emphasize safety, as well as all federal, state, and local government
and accreditation organization safety requirements and standards.
 B. Implement measures to promote quality and a safe environment for patients, self,
and others.
 C. Formulate goals and outcomes using evidence-based data to reduce patient risks.
 D. Obtain instruction, supervision, or training as needed when implementing nursing
procedures or practices.
 E. Comply with mandatory reporting requirements of the Texas Nursing Practice Act.
 F. Accept and make assignments and delegate tasks that take into consideration
patient safety and
organizational policy.
NPA
217.1&2

(B) Implement measures to promote a safe environment for clients and others;

(C)Know the rationale for and the effects of medications and treatments and shall correctly administer
the same;

(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-
efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the
ordering practitioner when the nurse makes the decision not to administer the medication or treatment;

(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions;

(S) Make assignments to others that take into consideration client safety and that are commensurate
with the educational preparation, experience, knowledge, and physical and emotional ability of the
person to whom the assignments are made;

(T) Accept only those nursing assignments that take into consideration client safety and that are
commensurate with the nurse's educational preparation, experience, knowledge, and physical and
emotional ability;

THE JOINT COMMISSION
The National Patient Safety Goals
www.jointcommission.org
http://www.jointcommission.org/standards_in
formation/npsgs.aspx
http://www.youtube.com/watch?v=X6nBd9Nv
qrk&feature=related
NATIONAL PATIENT SAFETY
GOALS -JAN. 1,2012
 Identify patients correctly
 Improve staff communication
 Use medicines safety
 Prevent infections
 Identify patient safety risks
 Prevent mistakes in surgery
IDENTIFY PATIENTS
CORRECTLY
 Use at least two ways to identify patients. For example,
use the patient’s name and date of birth. This is done to
make sure that each patient gets the correct medicine and
treatment.
 Correctly Indentify mother /baby couplet.
 Make sure that the correct patient gets the correct blood
when they get a blood transfusion.
IMPROVE STAFF
COMMUNICATION
 Communication
• Verbal
•
•
•
•
•
•
Handoffs
Reports
Nurse to Nurse
Nurse to Doctors
Other Nurse to other Health Care Team Members
Documentation
 Get important test results to the right staff person on
time.
What is SBAR and What is SBAR
Communication?
A Communication Technique for Today's Healthcare Professional
Situation Background Assessment Recommendation (SBAR) is a standardized way of
communicating. It promotes patient safety because it helps individuals communicate with
each other with a shared set of expectations. Staff and physicians can use SBAR to share
patient information in a concise and structured format. It improves efficiency and accuracy.
SBAR stands for:

Situation

Background

Assessment

Recommendation
Communication with physician.
“Dr. ________________, This is [state your name], one of the nurses in [state your department].
We have a new patient, [patient’s name], a [age] year-old, [race], [gender]. He came in with
complaints of________________________
_____________________________, which started at [time of onset].
His vital signs are [HR], [RR], [BP], [T], and [pulse ox, amount of O2 and type of delivery].
He has a history of ___________________________________________.
On assessment, we found______________________________________.
So far, we have [tell what interventions you have done so far].
I think he may have ________________________________________.
I think he needs some________________________________________.
What else you would like for us to do?”
Restate what needs to be done, including reading back the orders.
Confirm when the health care provider will arrive to assess the patient.
PLEASE USE CUS WORDS
BUT ONLY WHEN
APPROPRIATE!
USE MEDICINES SAFELY
 Before a procedure, label medicines that are not labeled. For example,
medicines in syringes, cups and basins. Do this in the area where medicines
and supplies are set up.
 Take extra care with patients who take medicines to anticoagulants.
 Record and pass along correct information about a patient’s medicines.
 Find out what medicines the patient is taking. Compare those medicines
to new medicines given to the patient.
 Make sure the patient knows which medicines to take when they are at
home.
 Tell the patient it is important to bring their up-to-date list of medicines
every time they visit a doctor.
Improve the safety of using medications.
• Identify and, at a minimum, annually review a
list of look-alike/sound-alike drugs used by
the organization, and take action to prevent
errors involving the interchange of these
drugs.
• Label all medications, medication containers
(for example, syringes, medicine cups, basins),
or other solutions on and off the sterile field.
• Reduce the likelihood of patient harm
associated with the use of anticoagulation
therapy.
LOOK ALIKE MEDICATIONS
http://www.usp.org/images/patientSafety/prn1162004-04-30h.jpg
http://www.uspharmacist.com/publish/images/8_1307_3.jpg
MEDICATION ERRORS
 http://www.youtube.com/watch?v=uQ-Vns6XFc&feature=related
PREVENT INFECTION
 Use the hand cleaning guidelines from the Centers for Disease
Control and Prevention or the World Health Organization. Set goals for
improving hand cleaning. Use the goals to improve hand cleaning.
 Use proven guidelines to prevent infections that are difficult to treat.
 Use proven guidelines to prevent infection of the blood from central
lines.
 Use proven guidelines to prevent infection after surgery.
 Use proven guidelines to prevent infections of the urinary tract that
are caused by catheters.
INFECTION CONTROL
STARTS WITH
HANDWASHING
HIP HIP HOORAY
DR SEMMELWEISS
IDENTIFY PATIENT
SAFETY RISKS
 Find out which patients are most likely to try to commit
suicide.
 Falls
 DVT
 Infant abduction
PREVENT MISTAKES IN
SURGERY
 Make sure that the correct surgery is done on the
correct patient and at the correct place on the patient’s
body.
 Mark the correct place on the patient’s body where the
surgery is to be done.
 Pause before the surgery to make sure that a mistake is
not being made.
SURGERICAL TIME OUT
PROCEDURE
 Even for an emergency C-Section or a BLT
 http://www.youtube.com/watch?v=w7GE_YvPVh4
 http://www.youtube.com/watch?v=lEzwBvByIiE
STANDARDS OF CARE
 AWHONN
• http://www.awhonn.org/awhonn/
 Nann
• http://www.nann.org/
 ANA
• http://www.nursingworld.org/
 AACRNA
• http://www.aana.com/Pages/default.aspx
INSTITUTE OF MEDICINE
(IOM)
 http://www.iom.edu/Global/Topics/Quality-PatientSafety.aspx
AGENCY FOR HEALTHCARE
RESEARCH AND QUALITY
 www.ahrg.gov
PATIENT SAFETY QUALITY
HEALTHCARE
 www.psqh.com
INSTITUTE FOR
IMPROVEMENT
 www.ihi.org/ihi
INSTITUTEFOR SAFE
MEDICATION PRACTICES
 www.ismp.org
NCLEX
 Client needs
 Safe and Effective Care Environment
 Safety and Infection Control
 www.ncsbn.org
.
 Safety and Infection Control – protecting clients and health care
personnel from health and environmental hazards.
 Related content includes, but is not limited to:
 ..Accident/Injury Prevention
 ..Emergency Response Plan
 ..Ergonomic Principles
 ..Error Prevention
 ..Handling Hazardous and Infectious Materials
 ..Home Safety
 ..Reporting of Incident/Event/Irregular Occurrence/Variance
 ..Safe Use of Equipment
 ..Security Plan
 ..Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
 ..Use of Restraints/Safety Devices
WHAT ARE SAFETY
ISSUES WITH THE
MATERNAL/NEWBORN
AND WOMEN’S HEALTH
CARE PATIENTS?
ARE YOU PREPARED TO
PROVIDE SAFE CARE?
 Read Tx Bon Rules on Safe Nursing Care and NPA
 Read the National Safety Goals by the Joint Commission
 Read Standards of Care by AWHONN or NANN
 Read Hospital Policies and Procedures
 Read your Textbooks
 Read Evidences-Based Practice Nursing Journal Articles
REMEMBER
 Keep your Patient Alive

http://www.youtube.com/watch?v=7wTPvl_QP34
 Keep your Patient SAFE

http://www.youtube.com/watch?v=IEGDLJinzDE&feature=fvsr
 Keep your Patient HAPPY

http://www.youtube.com/watch?v=WIM3GHvBQjY
 Communication/Document correctly and in a timely manner.
http://www.youtube.com/watch?v=1PENZkWqqUk
http://www.youtube.com/watch?v=1ym11J8NbMg
QUESTIONS
YOUR TURN
Can You answer the following
questions?
QUESTIONS
 1. SBAR stands for:


S ________________________________

B________________________________

A________________________________

R________________________________

SBAR
S Situation
Describe the situation
WHAT IS GOING ON NOW
B Background
Deliver a concise history
WHAT HAS HAPPENED
A Assessment
Use your best Judgment
WHAT DO YOU THINK IS WRONG
R Recommendations
What needs to happen?
WHAT WOULD YOU SUGGEST HAPPEN ?
According to the Joint Commission for the Accreditation of
Hospitals, what was the root cause of nearly 80% of all
sentinel events between 1995 and 2005?
a. Communication errors
b. Inappropriate staff mix
c. Insufficient orientation of new RN’s
d. Leadership failure
Communication errors
Describe one
communication tool that
the RN can use to increase
patient safety.
http://www.youtube.com/watch?v=RwUG
SYDKUxU&feature=fvwrel
SAFETY DANCE
 http://www.youtube.com/watch?v=B64vsqn8oiY&playne
xt=1&list=PL6073914211EA7949&feature=results_main