and actions promoting patient safety; organizational learning; management support for patient safety; overall perceptions of patient safety; feedback and communication about error; communication openness; frequency of event reporting; teamwork across units; staffing; handoffs and transitions; nonpunitive response to errors; number of events reported; and asks the participant to assign a patient safety grade to the organization. The Patient Safety Culture surveys are available in English and Spanish and are publicly available at no cost on the AHRQ website.
AHRQ also created databases for Patient Safety Culture survey data from organizations that administer the surveys. The databases allow health care organizations to compare their patient safety culture survey results to similar sites in support of patient safety culture improvement. Survey results are used by organizations to raise staff awareness about patient safety; assess and diagnose the current status of the patient safety culture; identify strengths and areas of opportunity for patient safety culture improvement; examine trends in patient safety culture changes over time; evaluate the impact of patient safety initiatives and interventions on the culture; and conduct internal and external evaluations the culture of safety. AHRQ provides an Action Planning Tool to assist an organization in analyzing and improving their patient safety culture.
The Safety Attitudes Questionnaire was developed with funding from the Robert Wood Johnson Foundation and the AHRQ. The 36‐item survey obtain frontline staff perspectives about specific patient care areas. The key factors that are measured include teamwork climate; safety climate; perceptions of management; job satisfaction; working conditions; and stress recognition. The survey is used by health care organizations to compare themselves to other organizations; identify interventions needed to improve safety attitudes; and measure the effectiveness of the interventions.
Chassin and Loeb (2013) developed a grid to allow health care organizations to assess their stage of organizational maturity toward becoming an HRO: beginning, developing, advancing, and approaching. Chassin and Loeb identified performance based on Position (Board, CEO/Management, Physicians); Initiatives (quality strategy, quality measures, and information technology); Safety Culture (trust, accountability, identifying unsafe conditions, strengthening systems, and assessment); and Robust Process Improvement (methods, training, and spread). Their grid may be used by leaders to assess their journey toward becoming an HRO.
Informatics
In this final QSEN competency, nurses use information and technology to communicate, manage knowledge, mitigate errors, and support decision making. Direct care nurses apply technology and information management tools to support safe processes of care. They effectively navigate the EHR and respond appropriately to clinical decision‐making supports and alerts. They use information management tools to monitor outcomes of care and they use high quality electronic sources of health information. Nurse leaders ensure that nurses participate in the selection, design, implementation, and evaluation of information technology. They also anticipate unintended consequences of new technology and participate in the design of clinical decision support systems.
Intravenous pumps with built‐in limits for medication doses serve as an example of technology that assists in preventing catastrophic medication errors.
Critical Thinking 4.3
Tina is caring for a patient with pulmonary emboli. She reviews the medication orders to administer 80 units of heparin per kilogram by intravenous bolus, followed by 18 units per kilogram as an hourly infusion. Tina knows her patient weighs 161 pounds, or 73 kg. She correctly calculates and administers the initial dose of 5,840 units. Tina calculates the continuous infusion rate at 1,314 units per hour. When programming the pump, however, her finger slips and she enters the numbers 11,314 into the pump. Because the programmed dose is beyond the normal range for heparin, the pump does not administer the drug, and Tina receives an error message from the pump. She quickly identifies and corrects the programming error. An independent double check from a peer for this high‐risk medication would also catch this programming error before it reaches the patient.
Answer these questions:
1 What factors may have contributed to this programing error?
In this scenario, the IV pump caught the error because the dose was excessive. What other strategies could Tina use to catch a programming error before it reaches the patient?
In an HRO, health information technologies help facilitate and sustain quality improvement efforts to improve patient safety. Using health information systems to document care and gather quality and safety information is essential. Additionally, health care information systems provide a method for reporting errors and near misses. The lack of health information systems can impede progress to an HRO. Health care organizations are challenged to devote scarce resources to implement information systems that require significant capital expense and ongoing maintenance costs. In addition, hospital leaders sometimes apply technology to faulty health care processes. Technology can only help improve health care processes when applied appropriately. As part of technology implementation, safe health care processes must be designed and technology must be used to support and sustain the improvements. As seen below, telehealth technology can also be used to make resources available to patients and clinicians remotely (Figure 4.7).
Sources: Joshua Kocoj, Amber Mills, Jonathan Miskus and Riley Wayco.
Informatics can also help organizations to identify events that cause harm to patients in order to select and test changes to reduce harm. The Institute for Healthcare Improvement Global Trigger Tool (IHI, 2017) helps health care organizations get a clearer understanding of the safety of care by measuring risk and harm at the hospital level. The Global Trigger Tool (GTT) uses specific patient care triggers as indicators that an adverse event may have occurred. Using GGT to identify adverse events (AEs) is an effective method for measuring the overall level of harm from patient care in a health care organization. GTT provides an easy‐to‐use method for accurately identifying AEs (harm) and measuring the rate of AEs over time. Tracking AEs over time is a useful way to tell if changes being made are improving the safety of the patient care processes.
More than 50 triggers are consolidated into categories on the GTT related to the provision of surgical, ICU, perinatal, medication, and emergency department care (Institute for Healthcare Improvement, 2018). For example, transfer to a higher level of care is one of the Global Triggers. Consider a situation where a patient is transferred from a medical–surgical unit to the ICU due to a rapid drop in blood pressure and decreased level of consciousness. This event would activate a trigger. The patient's EHR would be reviewed to determine what happened to the patient, when it happened, and if it could have been avoided. In an HRO, investigation results and the GTT results are shared with health care providers and process improvement changes are put into protocols, policies, and procedures to reduce the chance of future safety problems occurring. In an HRO, a multifaceted reporting approach is needed that is comprehensive and provides accurate measurements of errors and near misses.
Resources for the Journey toward High Reliability
Increasingly, the government is mandating public reporting for healthcare safety, quality, and financial indicators. This transparency holds health care providers and organizations accountable for quality care and is designed to help the consumer make informed choices about selecting health care providers. Public awareness of medical errors, poor quality outcomes, and perceived low value are driving changes in health care. Multiple groups are now focused on safety in health care. Many resources are available to nurses in the journey toward high reliability. Resources include