§  – freedom from accidental injury

– egregious event

·         Ex. Pt committing suicide, baby kidnapped, wrong site surgery

·         Adverse event that resulted in disability, death

·         Must be reported to the Joint Commission

·         Must perform root-cause analysis of event

situation, background, assessment, recommendation

·         Method of effective communication both for interprofessional communication and nurse to nurse communication

·         Handoffs may be facilitated through the use of standardized change of shift reporting checklists

§  Culture of safety

·         Acknowledges the influence of complex systems and human factors within the healthcare delivery system in general and within nursing practice specifically

·         Culture is not necessarily uniform within a single organization – each discipline/patient care area can have a different culture

·         Focus is on effective teamwork to accomplish the goal of safe, high-quality patient care

·         When adverse event occurs, the focus is on what went wrong, not who is to blame

§  Culture of safety

·         Elements of culture of safety

o   Establishment of safety as an organizational priority

o   Teamwork

o   Pt involvement

o   Openness/transparency – acceptance of human elements in errors; important so that errors and potential problems are exposed and solved before they endanger others (“just culture” – discipline is limited to reckless/egregious behavior)

o   Accountability

o   Non-punitive response to adverse events/errors

o   Promotion of safety through education and training

o   Emphasis on accountability, excellence, honesty, integrity, and mutual respect

o   Safety principles – designing jobs and working conditions for safety, standardizing and simplifying equipment, supplies, and processes and avoiding reliance on memory

§  6 core QSEN competencies

·         Pt-centered care – recognize pt as the source of control and full partner in providing compassionate and coordinated care based on respect for pt preferences, values, and needs

·         Teamwork and collaboration – function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality pt care

·         EBP – integrate best current evidence with clinical expertise and pt/family preferences and values for delivery of optimal health care

·         Quality improvement – use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continually improve quality and safety of health care systems

·         Safety – minimizes risk of harm to pts and providers through system effectiveness and individual performance

·         Informatics – use information and technology to communicate, manage knowledge, mitigate error, and support decision-making

§  Patient-centered care

·         Respectful and responsive care based on pt values

·         Pts and families should be the center of the care process

·         Including pts and families in decisions about treatments

·         Comprehensive discharge planning and education

·         Swiss Cheese Model of Accident Causation 

AKA: reason's adverse event trajectory

-When a system fails, the immediate question should be why it failed rather than who caused it to fail; e.g., which safeguards failed?

-These include institution triggers such as  incomplete or overly complicated procedures and policies. framework describes the numerous triggers that can set up a sequence of events that may cause an error to occur.

Organization triggers such as patient flow pressures, professional triggers such as delegation authority, team triggers such as inadequate communication training, individual triggers such as distractions, and technical triggers such as universal connections.

Multiple defenses set up to prevent errors from occurring occasionally line up so that multiple triggers align to allow an accident to occur.

Hence the name Swiss Cheese Model – the holes are aligned.