Good care, good health care, good nursing care is safe care. We need to keep that in the front of our minds as we're interacting with our patients, whether the patients are individuals, families, or groups, or communities. We're always looking at safety issues, safety from the patient's perspective and their environment, but also and probably more so safety in...
how we provide care to them. When we talked about the Code of Ethics from the American Nurse Association in the first part of the semester, on provision three of the ANA Code of Ethics, it reads, the nurse promotes, advocates for, and protects the rights, health, and safety of the patient. So safety is one of our foundational Code of Ethics standards as a profession. On that same discussion, we looked at common principles of ethical behavior. Two of them are very much tied into safety and the need to focus on safety.
One is the principle of beneficence, which is to do good. So we're only going to do things that are safe and in the patient's best interest. And the other is non-maleficence, which is we are going to do no harm. So we're going to be very careful not to do anything that violates the safety or makes the patient's situation less safe for them.
So again, safety is the essential part of nursing and this content or this module is divided into two sections for the lecture recordings. The first section, we're going to look at some basic concepts tied into safety and the readings for those are from the fundamentals text and they are in chapter 5. 5.2, 5.3, and 5.5. The objectives point out where I want you to be looking at in those sections for your readings. And then also there is a link to the 2023 National Patient Safety Goals.
I'll talk about those in a couple slides, but I'd encourage you to use that hyperlink from the reading guide to go and just familiarize yourself with... the national patient safety goals and particularly the current ones. We're going to start out by talking about Maslow.
Maslow is not a nursing theorist. He's a psychologist who roughly about 50 years ago developed this concept of a hierarchy of needs. As a psychologist, Maslow was trying to identify what was necessary for humans to become as fully human as they possibly could. How could they become the best of themselves? And he set that goal as being self-actualized individuals, individuals who were very high in their moral conduct.
They were creative, spontaneous, just sort of the best of the things that we can possibly be. As he was trying to understand or describe what is involved in reaching that level, if it can be reached. which was one of his conclusions. It's very rarely reached.
It's more of a goal to be attained. He realized that we can't focus just on that and move directly to that, that as individuals we have to address a series of other needs, more basic needs, sort of lower level concerns compared to self-actualization. And we need to do them in sequence to be able to even consider becoming self-actualized individuals.
So he broke those levels down at the very basic as physiological or physical needs, then looked at safety issues, then moved up to relationship issues, and then feelings of self-worth or self-acceptance. And then once all those needs were met, the individual hopefully can move into that stratosphere of self-actualization. He set it as a pyramid because, again, we need to take care of the most basic things that are foundational to anything above them.
So it's sort of a sequential journey that we go on. Nursing has adopted Maslow's hierarchy of needs as sort of a foundational theory of human development because it has application to what we do as nurses in the Road State program as well as other nursing programs. When you look at their organizational structure, organizational philosophy, you will find that Maslow's hierarchy of needs is cited as an important component of their philosophical foundation and what the program is based on. So for nursing in particular, we really focus on the idea that basic needs need to be met before we move on.
So similar to Maslow having this concept of self-actualization as a goal, our focus as nursing is to enable our patients, again, whether it's individual, group, or community, to become as healthy or have as important. have as great a sense of wellness as they possibly can. And our interactions are usually tied around the fact that there are some physiological or safety needs that aren't being met that are keeping that from happening. So as we look from a nursing perspective, our primary focus from a Maslow hierarchy approach is on physiological needs and safety needs.
So physiological needs, you've been involved with that in lab when we're doing the head to toe assessment. and vital signs. Those are examples of data gathering or assessment information that we gather that helps us identify are there any any deficiencies, any problems in physiological needs, ABCs, the airway breathing and circulation falls into that physiological. As you move through the nursing program and you start looking at issues that affect the various balances in our bodies things could that we determine is homeostasis. So we're looking at fluid balances, electrical balances, electrolyte imbalances, any of those types of things.
Those are all physiological needs and that's where you're going to be focusing a lot of your studies over the next several semesters as you move forward. From a safety perspective, we are looking through the assessment and our interaction with our patients that not only looking what their safety needs are, but we're also looking particularly at the safety of the environment within which we're providing care. So if we do not create a safe environment, it's going to be difficult for us to assist our patients to meet their physiological needs and be prepared to move on towards a greater sense of wellness. So again, from a nursing perspective, We're really going to tap into Maslow's physiological and safety levels of needs as our starting point as we move into the nursing process and use the nursing process.
In orientation day or early on, there's a good chance I used the phrase of a good day for nurses. That's sort of a tongue-in-cheek, somewhat irreverent approach would be a good day is any day when everybody's still breathing at the end of the day. Everything else becomes workable.
Again, that is an example of nursing dark humor on how we can look at things, but we can use that concept to identify what then would be a bad day. What would be a day that definitely indicates we need to focus on some things so that we're harmed. So a bad day can be identified by what events happen in it. A bad day is the day where there is, again the most obvious would be that somebody's not breathing, a patient is not breathing at the end of the day that that should be, that there's no reason for that.
So death of a patient becomes potential grounds for a bad day. We can term these situations as events. And there's three types of events that go into making or indicating that the day has not gone in the way it should, that there have been safety issues that have resulted in harm to our patients. So the first type of events are never events. These have been identified and established by regulators, including Joint Commission.
Federal health care agencies, insurance groups have all come together identified never events. These are events that never should happen. Never events are identifiable. You can see the situation.
We can see what possible consequences are. They're measurable. We can identify what steps are involved in this care, this situation.
The outcome of these events is serious. By serious, we mean that these are resulted in the death. or the severe disability of the patient. So not...
an outcome that was desired or approached and extremely serious. So again, in this case, when we talk serious, we mean it's either death of the patient or severe disability, and it's a result of the event happening. The other part of a never event is that it's preventable. Your text and reading gives the categories that are looked at as never events.
It involves medication. It involves procedures. So glance through that list or spend a little bit of time in that list and look at what those categories are. And on each of them, it gives an example of what would fall under that category.
But again, the biggest thing about never events are they are things that are preventable. They happen because safe standards, safe practices were not followed. And so the consequences of this never event really fall back on the organization and the individuals involved.
Never events and the next types of sentinel events are both reportable. They're reportable to the government, and those results are public information. The consequences of never events, or as we get into the next one, the sentinel events, occurring by...
within an organization may affect their payment. There's going to be consequences. If a patient suffers severe disability or again dies as a result of a never event happening, the payer for that care, whether it's Medicare or an insurance company or Medicaid, will very likely withhold payment.
The organization has to, will be held accountable financially for that misstep, as well as most likely looking at some legal actions on the being taken on behalf of the patient. So again, in every event is something that results in a serious, either fatal or severe disability to a patient. Through a process of procedure actions on the part of the organization and individuals within the organization.
where it's identifiable and predictable that by not following proper procedure, this outcome was anticipated, could be anticipated. And as such, it's preventable just by doing the right things. The next kind of event is sentinel event. Sentinel events are events, again, they're serious.
They are either fatal or result in... severe disability for the patient. Sentinel events can include the never events, but it also includes the events where everything in terms of procedurally, if it's a procedure related event, or if it's a medication related event, that's the right medication is being used, but something happens that's not foreseeable. So in this case, sentinel events can include those never events, but it also includes events that have the serious outcomes that we All right, weren't expecting, may not have had any specific reason to expect, but it did result in this negative outcome. So the question that needs to be answered is, was this event preventable?
So again, with never events, these are events that have been identified as always being preventable if the organization individuals are doing the right thing. A Sentinel event that's not a never event, that question needs to be answered. Third type of event that we want to look at are near misses. These are events or actions that potentially could develop into sentinel events. They have the potential for having serious negative outcomes.
But for some reason, either because the factor that was leading to the serious outcome was identified at the last minute, used for checks and balances, may have just been, as you call it, luck or grace of God, that the negative outcome didn't happen, but it was potentially there. This is reported within the organization and followed up within the organization to see what was going on that led to this near... Sentinel event and what can be done to make sure we don't get there again.
So with each of the events, again, the Sentinel event and Never events are reportable and will become part of the public record. The near misses will be handled internally probably, but all three of these situations will result in actions by the organization to try to identify, understand what happened, how these events came to be or nearly came to be. And looking at that through a process called root cause analysis.
The investigation of these events is not focused on finding out who to blame, but to look at what was the big picture, what are the factors that led to this even possibly happening, as well as the fact that it did happen. So root cause analysis is a systems-wide approach. It looks at the systems, the relationships, the actions, the equipment, anything that could be related to the situation to find out how were they factors, are the things going to be changed, as well as looking at the human factor.
Was it just a poor judgment or was poor judgment on top of the other things? So again, root cause analysis is looking at a systemic as well as human involvement in these errors happening. these events taking place. As a nurse, you're going to be involved in practices and procedures to help prevent these things from happening. If you happen to be involved in a situation where a never-event, sentinel event, or near-miss does occur, you will be part of that root cause analysis procedure in terms of...
helping provide information of if you were directly involved of spending time to find out what were your processes what contribution did you may or may not you may or may not have had in that event so again it's a very in-depth view with the goal of making sure that this does not happen again as a result of The reporting of Sentinel events, of NEVER events, as this data is collected over the years, there have been a number of initiatives that have been put forth by various organizations as a response, and what they are are best practice behaviors to help organizations make sure they do not have this Sentinel event or this NEVER event occur. So again, particularly with never events, these are the practices that make it preventable. So as you look at the categories of never events, one of the categories is medication.
So there is a number of interventions or a number of initiatives that have come out to help decrease the number of medication errors. Because you'll hear in your clinical classes in pharmacology, medication error is a massive problem. problem in our culture.
It is very costly in terms of life and wellness as well as being very costly in terms of dollars related to problems as a result of medication errors. So your readings talk about some of the initiatives and they involve lists. If you have some time, you'll be talking about these more as you get in your clinical classes, you'll be working with them as you go into your clinical site.
sites and when you go into the workforce later on. But some of these lists are error-prone abbreviations. There's a sub-list of this that came out of the regulators that hospitals will have usually posted and make part of nursing orientation, orientation of any staff.
We talk in health care in our own language. In that language, a lot of times it involves abbreviations or initials. STAT, PO, ECG, just a number of things that are a shorthand way of relaying information. As long as that information is clear to everybody, it's not an issue.
When it comes to medication over the years, there were a number of abbreviations that have been used, particularly in terms of timing of a medication, frequency, as well as dosing type things. that were easily confusable. So a lot of those abbreviations had basis in Latin terms. So we're looking at frequency. If something was daily, we listed it as QD for every day.
If it was every other day, it was QOD. If it was four times a day, it was QID. And all those came from Latin terms that were identifiable if you understood Latin and you were using them frequently.
A couple issues that became clear. is one, not everybody understood the initials over time, or they would glance at them very quickly, and particularly in the days where we were doing a lot of things handwritten as far as orders and charting, that it was hard to identify what was being written. Sometimes the letters just sort of ran together.
So even with the change to electronic records by most institutions, we still operate under a do not use list of abbreviations. So the QD, the QID, QOD are examples of things that are never to be used. Whenever you're documenting, even though it's nice to use a shorthand approach to keep your documentation brief, write things out.
Another area in terms of abbreviations that, particularly when we were doing a lot of handwriting and writing narrative notes as nurses, A lot of times individuals would bring in their own abbreviations that made sense to them, but for somebody following, it was not really clear what they were talking about. And particularly when we're talking about medications and assessments and patient conditions, we can't afford from a safety standpoint to have confusion. So that's where the error-prone abbreviations came from. There's a number of drugs that either in their trade names or their generic names or a combination of both sound alike, sound very similar, but they're extremely different medications.
There's a Klonopin and a Klonodine. They sound alike, but they're two totally different classes used for two totally different things. So the list of confused drug names is going to be available at most institutions.
It may be posted near the medication. dispensing area. Just as a reminder, double check when you're pulling medications that you're pulling the right medication.
Just because it sounds right doesn't mean it is right. So that's again a list of names that come from there. Occasionally you'll see some of those names spelled with certain parts capitalized in the middle of the word.
It's not a misprint. That's called Tallman branding or tall man documentations just to help call attention to the fact this is an easily confused drug make sure you're pulling the right one high alert medications are medications that even when they're used for what they're supposed to be used for if we do even slight improper dosing or frequency we can cause major harm these would be high alert medications so things like insulin a heparin and some other blood thinners potassium as electrolyte replacement. Just a number of medications. Again, these lists are going to be made available to you in your clinical site, ease of their policy and procedures. Hopefully they'll be posted near the medication area where you obtain your medications.
Several of the medications will be labeled from the pharmacy. They'll have special tags on them just to make sure, again, that we are paying close attention because they have a high risk for causing harm. And the last list that's given in the reading is the do not crush. There's certain medications that if we crush them to put them down, say, a tube for somebody who's not able to swallow, and normally we would crush the medications and sort of rinse it down and use a syringe to administer. There's certain medications that we can't do that.
Their ability to work is compromised. And so you're going to run into a list of medications, or when you do your research on drugs and certain medications, you're going to see in bold print, do not crush this medication. So again, all these were safety initiatives that were generated to cut down on the issue of medication errors that were causing harm to our patients, potentially up to death.
Another category in those never events were procedure-related, surgical and procedure-related. Surgery and the various invasive procedures we do, there's a set way of doing them. And the providers, the nurses involved, are trained in those procedures, are trained in that sequence of events.
Occasionally, however, We take for granted that we have the procedure down pat, and we at that point accidentally forget a step. So checklists, particularly surgical checklists or procedural checklists, have been developed. Your text gives an example of the surgical checklist that is adopted by American hospitals and it comes from World Health Organization. Again, they look like really common sense type things, but by putting on a checklist, we make sure that each step is addressed prior to the patient going into surgery.
Again, it helps us avoid death of a patient, helps us avoid things like having the wrong part of the body operated on, which seems like how could that happen, but it has happened. And so that's where checklists come in, particularly with procedural type situations. Another area where care can become compromised and we can cause safety issues for our patients is in communication. It's very important that we know what's been going on with the patient before we assume our role in caring for them. It's very important when we pass that care on to someone else that they know what's going on, that they have a really full and clear picture of what's happening.
So again, some safety initiatives around communication have been implemented over the years. A couple examples here and we're going to give you a chance to practice with these later in the semester in lab, but right now just want you to be familiar with are the SBAR or ISBAR and the Handoff Report. And again your text gives you a description of what the letters in ISBAR stand for.
Essentially if you're on We want to look at situations. This is when a nurse needs to call a provider. The physician, the nurse practitioner, the physician assistant, whoever's coordinating care, possibly another discipline that we need assistance from and one of the therapy groups. The SBAR would be a way of preparing your phone call to make sure you cover the points. Over the years I've worked with a few nurses and talked with a few of the physicians that they called in the middle of the night and became really clear that they were not taking the time to prepare their communication.
They gave a lot of extraneous information that the provider really didn't care about and they took forever to get to the round the point of why were they even calling. So that's what the SBAR communication technique does. It allows us to focus The reasons for our communication to the provider that we're calling gives them the situation background. It just breaks it down so we have basically a formula to communicate that gets the key information to the provider and also ensures that we get the response and documents response and understand the response accurately. So that would be the SBAR or ISBAR.
The handoff report is when we're transferring care. So this can be an end of shift when we report off to the oncoming nurse to make sure they know what's been happening so they're better prepared to take care of the patient and know what things to be watching for. If we're transferring the patient to another area of care, so moving a patient from the floor back to surgery, moving a patient from a medical, surgical, or basic level of care up to a critical care area or from the critical care area back out. or transferring the patient to another facility, whether it be a discharge to an extended care facility or a transfer to a higher level of care facility for more advanced treatment. So the handoff report, again, is developing a structured approach to make sure we're covering key points, that the information that the individuals who will be assuming care, that the information they need is available to them.
So again, these are just a few of the safety initiatives that have come out from dealing with sentinel events and never events. In terms of having a really focused identification of where do healthcare organizations need to concentrate on safety issues based on these never events, sentinel events, other data that's collected, joint commission. which is an accrediting body for health care organizations, has taken the lead on that.
So they take that information and annually they publish a listing of national patient safety goals. So the source for national patient safety goals is the Joint Commission. Again, it's looked at annually. So there can be changes from year to year. Identify these goals again based on information safety issues that have been reported.
So again, never events sent no events as they're dealing with the organizations that they accredit looking at what sort of near misses or what sort of internal studies they've done. They'll identify what are the key things. So again, it's reviewed annually. This is a listing of 2023. National patient safety goals as far as what organizations or facilities they cover.
So joint commission against accrediting bodies. So these goals are going to apply to agencies that are or could be accredited through joint commission. So we're looking at the ambulatory care, we're looking at hospitals, home cares, labs, extended care facilities. It's a whole gamut of things, but they're all healthcare organizations that either can be or are accredited by Joint Commission or similar agencies. I did pull the list of the 2023 National Patient Safety Goals from their website.
Again, you don't need to memorize these but just look down through and be familiar with some of the key ones. The fact that patient identification, the fact that we're having you identify your patient. with each encounter with name and date of birth.
That is a component of the national patient safety goals and has been a fairly constant over the years. Currently we're looking at issues at a national level of risk of patient harm from falls. So again that's going to be based on the number of reported falls over the last few years, that type of thing. So as you look there are some things here that are individual to the patients and things are focused on key areas like medications. There's also things that are looking at environmental issues.
When we look at the bottom of the list, that an organization identifies safety risks that is based on their patient populations. It's not telling us what those risks are, it's just saying an organization has to have a process in place where they are assessing their patients to find out what kind of risks do they, as in their particular setting, need to be aware of. The idea of improving health care equity, that's a systems issue.
that each facility is responsible showing they have processes in place to make sure all patients are getting equitable access to care. So again this is the full list of national patient safety goals. If you have a chance to go to the website and look through you'll also realize that not every organization has every one of these goals applying to them.
Some of the goals are applicable primarily to assisted living and extended care type facilities. A few of the goals are primarily hospitals and lab hospital related organizations. A few are related specifically to home care or maybe to labs.
So again, this is the total picture, but then it's broken down or focused based on the type of organization. Again, just be aware national patient safety goals become a focus of care, a focus of quality. They're generated by the Joint Commission and distributed out to all the applicable organizations. In the next section of this module, we'll look at some specific areas of patient safety.