Describe processes used in understanding causes of error and allocation of responsibility and accountability
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Identify one way that a nursing unit could address these areas:
Knowledge Skills Attitudes
Examine human factors and other basic safety design principles as well as commonly used unsafe practices (such as work-arounds and dangerous abbreviations) Demonstrate effective use of technology and standardized practices that support safety and quality
Describe the benefits and limitations of selected safety-enhancing technologies (such as barcodes Computer Provider Order Entry medication pumps and automatic alerts/alarms) Demonstrate effective use of strategies to reduce risk of harm to self or others
Value the contributions of standardization/reliability to safety
Discuss effective strategies to reduce reliance on memory Use appropriate strategies to reduce reliance on memory (such as. forcing functions checklists)
Appreciate the cognitive and physical limits of human performance
Delineate general categories of errors and hazards in care
Communicate observations or concerns related to hazards and errors to patients families and the health care team
Value own role in preventing errors
How does your unit address these issues or do they?
Knowledge Skills Attitudes
Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems)
Use organizational error reporting systems for near miss and error reporting
Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as root cause analysis and failure mode effects analysis) Participate appropriately in analyzing errors and designing system improvements
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Engage in root cause analysis rather than blaming when errors or near misses occur
Value vigilance and monitoring (even of own performance of care activities) by patients families and other members of the health care team
Discuss potential and actual impact of national patient safety resources initiatives and regulations Use national patient safety resources for own professional development and to focus attention on safety in care settings
Value relationship between national safety campaigns and implementation in local practices and practice settings
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