| NEW | 2026
What is the mission of the na onal safety founda on (NPSF)?
to improve measurably pa ent safety in delivery of health care by efforts to: iden fy and create
a core body of knowledge, iden fy pathways to apply knowledge, develop and enhance culture
of recep vity to pa ent safety, raise public awareness and foster communica ons about pa ent
safety and improve status of founda on and its ability to meet its goal
What are the safety concepts which originated from the IOM's groundbreaking work related to
pa ent safety?
safe, effec ve, pa ent-centered, mely, efficient, equitable
Just culture
a system's explicit value of repor ng errors without punsihmen
QSEN goals
nurses having the knolwedge, skills and a/tude to promote pa ent safety
human factors related to safety
ability or inability to perform exac ng tasks while a0ending to mu ple things at once
crew resource management related to safety
preven ng distrac ons, need for accurate communica on
ADEs (adverse drug events)
one of the most common types of inpa ent errors (5% of hospitalized pa ents); ambulatory
pa ents experience at higher rates
Most frequent pa ent errors occur
in transi ons of care due to miscommunica on
adverse event
unintended harm by an act of commission or omission rather than as result of disease process
near miss
, error of commission or omission that could have harmed a pa ent, but harm didn't occur as
result of chance
mi ga on
realizing a wrong dose has been administered and ac ng immediately with anecdote to avoid
harm
sen nel event
unexpected occurrence involving death or serious injury
Joint commission specific goals
1. iden fy pa ents correctly
2. improve effec veness of communica on among caregivers
3. improve safety of using meds
6. reduce harm associated with clinical alarm systems
7. reduce risk of health care-associated infec ons 9. reduce risk of pa ent harm resul ng from
falls
14. prevent pressure ulcers
15. organiza on iden fies safety risks inherent in popula on
16. universal protocol for preven ng wrong site, wrong procedure, wrong person surgery
elements of employee safety
blood and body fluid exposures, latex allergies, communicable disease exposures,
musculoskeletal injuries, immuniza on program, systemic review, follow-up and repor ng of
employee incidents
a0ributes of a care coordina on model
-Interorganiza onal and interprofessional team that includes the pa ent
-Communica on and informa on exchange
-A proac ve plan of care with goals
-Targeted set of purposeful ac vi es
-Proac ve follow-up
Goals of Hospital to home ini a ve
reduce 30 day readmissino rates using early follow up, post-discharge med management and
educa on of pa ent on signs/symptoms
How does medicaid improve pa ent transi ons?