Leadership (NUR 444) Exam 3 Questions and Answers

Leadership (NUR 444) Exam 3 Questions and Answers "To Err is Human" Findings (MP) - Ans:-results of several studies, when extrapolated to the 33.6 million admissions in 1997 imply that 44,000-98,000 Americans die each year as a result of medical errors - Deaths due to medical errors exceeded the number of deaths from: *MVC's (43,458) *Breast Cancer (42,297) *AIDS (16,516) *Total National Costs of Preventable Adverse Events are estimated to be between $17 and $29 billion annually *½ of the costs are related health care costs *Medication Errors: 2 out of every 100 hospital admissions experienced a preventable adverse drug event ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 2/49 Most adverse drug event data was hospital based but adverse drug events can occur in every setting Patient Safety Initiatives (MP) - Ans:-The Joint Commission National Patient Safety Goals began in 2003 and over the last 20 years have focused on: - patient identification - effectiveness of communication among caregivers - safety of using medications - medication reconciliation - reduce the risk of health care-associated infections - reduce the risk of harm resulting from falls (LTC) - reduce the risk of pressure ulcers (LTC) Identify patients at risk for suicide - reduce the risk of home oxygen (HC) - universal protocol for procedures - improve the safety around device alarms ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 3/49 The Center for Medicare/Medicaid Services (CMS) identified certain hospital-acquired conditions that would no longer be paid for including: - foreign object retained after surgery - air embolism - blood incompatibility - falls, trauma, injuries occurring in the hospital - stage 3 and 4 Pressure Ulcers - catheter-associated urinary tract infection What are the five principles of High Reliability Organizations? (MP) - Ans:-- Sensitivity to Operations - Preoccupation with Failure - Reluctance to Simplify - Commitment to Resilience - Deference to Expertise ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 4/49 What is a Just Culture? (MP) - Ans:-A Just and Fair Culture is one that learns and improves by openly identifying and examining its own weaknesses; it is transparent in that those within it are as willing to expose weaknesses as they are to expose areas of excellence. In a Just Culture, employees feel safe and protected when voicing concerns about safety and have the freedom to discuss their own actions, or the actions of others in the environment, with regard to an actual or potential adverse event. Human error is not viewed as the cause of an adverse event, but rather a symptom of deeper trouble in an imperfect system. Leaders therefore do not rush to judge and punish employees involved in medical errors, but seek first to examine the care delivery system as a whole in order to find hidden failures and vulnerabilities. Performance and Process Improvement Approaches (MP) - Ans:-- Retrospective Audits - Quality Assurance - Reengineering and System Redesign - Rapid-Cycle Improvement (PDSA) - Six Sigma: DMAIC Methodology - LEAN: focus on reducing waste (non-value added steps) ©GRACEAMELIA 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED FIRST PUBLISH OCTOBER 2024 Page 5/49 - Transportation, Inventory, Motion, Waiting, Overproduction, Overprocessing, Defects (creates re-work) What is a patient safety event? - Ans:-occurs when an injury to a patient is caused by medical management rather than the patient's underlying condition What is an error of omission? - Ans:-results when an action that is a standard of care is not taken or omitted What is an error of commission? - Ans:-results when the wrong action is taken or committed What is unsafe act? - Ans:-occurs in the presence of a potential hazard, sometimes as the result of a violation, not an error What are slips, lapses, and mistakes? - Ans:-actions that