Fundamentals - Leadership, part 7: Quality Improvement, Patient Safety Events, Incident Reporting
by Meris Shuwarger BSN, RN, CEN, TCRN January 26, 2023 Updated: August 09, 2023 7 min read
- 0:00 What to expect
- 00:19 Quality Improvement (QI)
- 4:22 Patient Safety Events
- 8:48 Quiz time!
Hi. I'm Meris, and in this video, I'm going to be covering the quality improvement process along with different types of patient safety events. I'm going to be following along with flashcards from the leadership section of our fundamentals flashcard deck. If you have a set of your own, I would invite you to follow along with me. All right. Let's get started.
So first up, we are talking about the quality improvement or QI process, and this is what it sounds like. It's the process by which we find ways that we can improve the quality of the care that we deliver to our patients. This is very important. It goes right along with evidence-based practice. Right? If there's a better way to do something, we want to figure it out. We want to see how we can improve the quality of our care. So let's talk about the QI process. So the first step in the QI process is to establish the standard of care. So for instance, what is the benchmark or the best practice? So let's say we're talking about decreasing patient falls on the unit. So the benchmark is to have zero patient falls. Right? That's what we're saying. Or maybe you're working on improving something else and you're going to say, "We are okay with 2% XYZ situation." Figure out what that benchmark is because we can't work towards improving our quality if we don't know what we're working towards. The next step is to collect data and compare it against the benchmark and standard. So we say, "We want to have zero falls on this unit ever, and currently, we have had three falls in the past six months." Okay? So that's where we're going to do a chart audit, or we're going to look at those, I don't know, incident reports or something like that to figure out, "Where are we right now compared to that benchmark in comparison?"
Now, if the standard was not met, such as in that example, we need to perform a root cause analysis to understand the causative factors. So root cause analysis literally just means, "Let's analyze this situation and figure out what cause is at the root of this issue." Okay? Is it because there's a knowledge deficit? Our nurses don't know about how to prevent falls. Do we need more education? Is it an equipment issue? We don't have enough bed alarms. Is it an issue of we don't have enough staff? We don't have enough patient sitters to watch our high-risk fall patients. Things like that. What is the issue behind why we're not meeting that benchmark? The next step is to take the corrective actions to address the gap. So maybe we said we don't have enough bed alarms. Okay. Let's take the action of getting more bed alarms and see if that fixes the issue. And we will see that in the last step of the QI process, where we reevaluate to determine the effectiveness of the solution. So we got those bed alarms, we implemented them, and we let some time pass, and now we're going to reevaluate and see where we are in comparison to that benchmark. Maybe that fixed the issue and we can say, "Awesome. We did it. We met our goal," or maybe things stayed the same or got worse. Let's figure it out, and we're going to start back with one. Right? We're going to go through it again.
Now best practices. You've got to remember that QI is an ongoing process. You're never just done. You are never just at full top quality and there's nothing to improve. QI is an ongoing process, and we need to encourage employees to participate in the process and report any unusual trends to the QI team. For instance, at the hospital where I work, I was working as an ER nurse when we transitioned from one electronic health record to a different one. And this was a really great opportunity for nurses to participate in the QI process and say, "Hey, with our old system, we could do this thing, and that was very helpful to us, and it helped our workflow," and whatever, "but what this new system does, it doesn't let me do it this old way, and that really causes an issue because blah, blah, blah." That allowed me, as the nurse, to participate in the QI process. There's other examples too. Of course, if you see suddenly an increase in falls or you see an increase in catheter-associated UTIs, this is a good opportunity for you as the RN to get involved with that quality improvement process.
Now let's talk about patient safety events because these two go hand in hand. We want to improve our quality of care so that we can decrease the number of patient safety events. So a patient safety event is any event that could or did lead to harm in a patient. Right? It doesn't mean that it necessarily did, but it could have harmed a patient. So let's talk about some different types. The one I want you to know very well because it is one that you will experience much more frequently in your nursing practice is a near miss. So a near miss is an error that did not result in patient harm. It didn't reach the patient, but it could have. Okay? So for instance, let's say your patient was going to the operating room, and the preop nurse is there, and they're asking them, "So what procedure are we doing for you today?" And they're holding the patient chart, looking at it, and the patient says, "You're taking out my appendix," but the chart says amputation of left leg. And we'd say, "Oh. Oh my gosh. Okay. So I'm sorry, we're taking out your appendix. Okay. Right." That's a near miss. We didn't do the wrong surgery. No harm occurred to the patient, but it could have.
Now let's talk about an adverse event. An adverse event results in patient harm, but it may not be severe. So let's say I was starting a heparin drip, and I did a medication error in the heparin bolus. I gave double the amount of the bolus. That is an adverse event. It did reach the patient, and it could have resulted in harm. In this case, the patient is fine. It was just a small amount of heparin. Everything's good. We watched the patient. We monitored them. Everything is okay. That is an adverse event. Now a sentinel event. This is one that you've got to know it. You kind of just commit it to memory. You have to know it. A sentinel event results in temporary severe harm, permanent harm, or death of a patient. So if we did amputate that patient's leg when they were really there for an appendectomy, that's a sentinel event. If I gave the wrong medication and it killed a patient, that is a sentinel event. A patient who falls; that's an adverse event. Right? But a patient who falls and now is paralyzed for life; that's a sentinel event. A sentinel event. A sentinel is a beacon. Right? So think of a big flashing light, a big beacon saying, "This is not good." That's a sentinel event. Something really serious happened. It could be temporary but serious, it could be permanent, or it could result in death.
Now incident reporting. It is what it sounds like. It's reporting an incident. Right? But what this is, it's going to be documentation of a patient safety event, and this is used for the quality improvement process. Remember, we're going to maybe use this to help us figure out where we have areas for improvement. The RN should complete the report within 24 hours or per facility policy. Personally, I would not wait any longer than the end of that shift because you're going to start to forget things. So follow your facility policy. Within 24 hours is typically the best guidance, but personally, I would say within the end of your shift. Don't document this in your patient's chart. So let's say I did the medication error. I'm going to document it in my patient's chart, but I'm not going to say in that narrative note, "Incident report completed. Report number blah, blah, blah." Why? Well, the incident report is an internal document for the hospital. It is a facility document. It's not part of the patient's medical record. So what you're documenting about the event, "This is what happened. This is what was ordered. This is what was given. This is the objective signs of the patient. This is what I did. This is what the doctor said," all of that's great. That's part of their medical record. But you don't document the incident report because that's not part of their medical record. It's an internal document. Very important to know. I guarantee you you're going to have to know that, and you need to know that for your clinical practice, too, so you know what to chart and what not to chart.
All right. So that's it for this video. Are you ready for some quiz questions? Because I got a few for you. What is the first step of the quality improvement QI process? Establishing the standard of care. After corrective action has been taken to address a quality improvement gap, what should be done next? Reevaluate to determine the effectiveness of the solution. The nurse pulls a medication from the drug dispensing system and finds that losartan was stocked in the location where lorazepam was meant to be. The nurse reports this as which type of patient safety event? A near miss. Remember, the nurse recognized that the medication was different before administering it to the patient, so the issue did not reach the patient. It's a near miss. A patient is in a coma after falling out of bed and striking their head. What type of patient safety event is this? A sentinel event. Okay. And last question. In which section of a patient's chart should the nurse document completion of an incident report? The incident report should not be mentioned in the patient's chart as this is not part of their medical record.
All right. That is it for this video. I hope you learned something. If you have a great way of remembering something, please leave a comment below because you know I want to hear it, and so does everybody else. Thanks so much, and happy studying.
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