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Learning Module 17

Patient Safety: Our intent is khổng lồ vì chưng no harm – so why bởi errors happen?


The significance of errors in patient care has been highlighted in the literature và truyền thông since the 1999 sentinel work of the Institute of Medicine entitled To Err is Human: Building a safer health system. Using edquebecor.com competencies khổng lồ prepare students khổng lồ be vigilant around patient safety & to underst& the impact of errors, this module will giới thiệu examples of patient safety, just culture, & will cốt truyện some pedagogies using simulation lớn allow immersion into teamwork & collaboration khổng lồ promote safe patient care.

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Upon completion of this section, you will be able to:

Recognize the impact of errors on patient care, patients, families & healthcare providersDescribe processes used in understanding causes of error và allocation of responsibility & accountabilityDescribe the importance of interprofessional teamwork communication và collaboration in the integration of care and its impact on patient safetyDelineate the steps in error disclosure from risk management to transparency


Carol F. Dursay đắm, EdD, RN, ANEFJennifer Dwyer, MSN, RN, BC, CNRN, FNPhường. BC


Patient Safety: Our intent is lớn do no harm – so why vị errors happen? is situated in the context of the impact of errors on patient care, patients, families and healthcare providers. Using actual medical errors, the processes used in understanding causes of error & allocation of responsibility và accountability will be described. Medical errors have many contributing factors, yet interprofessional communication and collaboration continue to lớn be cited by the Joint Commission as the leading cause of sentinel events. TeamSTEPPS will be the framework for teaching effective interprofessional teamwork communication and collaboration techniques. Using collaborative sầu teamwork và effective communication are crucial to providing opportunities for learners lớn understand how to work together versus working in isolation & creating fragmented care. Once an error occurs, the next steps are essential for promoting patient safety. We will delineate the steps in error disclosure from risk management khổng lồ transparency.

Effective teamwork & collaboration is not easily taught using the more traditional approaches lượt thích discussing teamwork and communication in classroom even with the presence of interprofessional students. The learners need the opportunity khổng lồ be immersed in patient care simulated experiences which allow learners to lớn rehearse effective sầu communication techniques. In this module we will explore current teaching practices that enable and/or inhibit students lớn be collaborative practice-ready when they enter practice settings.

Patient Safety: Our Intent Is To Do No Harm – So Why Do Errors Happen?

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Just Culture – How Medical Errors Promote Patient Safety

The following đoạn Clip, referenced throughout this module và available to lớn us courtesy of Indiana University Health, captures a Patient Safety presentation by Cindy DeBord, RN.

Sections of this Just Culture video are linked from within the module nội dung. Those clips are listed below for ease of access:

1The Selective sầu Attention Test was developed through retìm kiếm conducted by Daniel Simons và Christopher Chabris in 1999. More can be found at their trang web (www.theinvisiblegorilla.com). The video clip is available for use in talks, training, and teaching on DVDs from Viscog Productions.


Patient Safety Starts With Me!!A printable bookmark (PDF) lớn keep patient safety at the forefront. Used with permission from Indiana University Health.

Teaching Strategies

The following are edquebecor.com Teaching Strategies referenced in this module.

Web Resources

Agency for Healthcare Retìm kiếm & Quality (AHRQ)This trang web has a wealth of information và resources including information on evidenced based practice, relevant research, patient teaching information, và consumer information around unique & safety. http://www.ahrq.gov/

Kimberly Hiatt’s Story“Nurse’s suicide highlights twin tragedies of medical errors”

Institute for Healthcare Improvement (IHI)The IHI is a not-for-profit organization leading the improvement of health care throughout the world. IHI website has information about programs, links lớn patient safety information, including the IHI mở cửa School: http://www.ihi.org/IHI/

Institute for Safe Medication Practices (ISMP)The ISMPhường is a nonprofit organization that educates healthcare providers and the public about safe medication practices. It has a plethora of resources for safe medication practices. http://www.ismp.org/

Institute of Medicine Health Care Quality InitiativeThe Institute of Medicine (IOM) (http://www.nationalacademies.org/HMD) is a nonprofit organization that provides science based information about health and science policy.

International Nursing Association for Clinical Simulation and Learning (INACSL) Promotes research & disseminate evidence based practice standards for clinical simulation methodologies and learning environments. http://www.inacsl.org/

Joint CommissionAccrediting body toàn thân for many health care organizations, concerned with improving the safety và unique of patient care. http://www.jointcommission.org/

National Patient Safety Foundation (NPSF)The NPSF is a not-for-profit organization whose mission is lớn improve sầu the safety of patients. http://www.npsf.org/

Quality & Safety Education for Nurses (edquebecor.com)The chất lượng & safety competencies are: patient-centered care, teamwork and collaboration, evidenced-based practice, quality improvement, safety, and informatics. Knowledge, skills và attitudes for pre-licensure education are outlined lớn clarify each competency. This site is a valuable resource because it also offers không tính phí downloadable teaching strategies and annotated bibliographies for each of the edquebecor.com competencies. https://edquebecor.com/ Be sure and explore the Teaching StrategiesLearning Modules!

The Future of Nursing: Leading Change, Advancing HealthRobert Wood Johnson Foundation Initiative sầu on the Future of Nursing, at the Institute of Medicine (October 5, 2010). Retrieved from http://nationalacademies.org/HMD/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx .

The Simulation Innovation Resource Center (SIRC) National League for NursingThe SIRC is an online e-learning site for nursing faculty khổng lồ learn about simulation and ways to lớn integrate it inkhổng lồ their curriculum. It provides various ways for faculty to engage with experts và peers. http://sirc.nln.org/

Society for Simulation in Healthcare (SSIH)Purpose is khổng lồ strengthen patient care through simulation education and retìm kiếm. http://www.ssih.org/

When Things Go Wrong: Responding to lớn Adverse EventsA consensus statement from the Harvard Hospitals that provides a format for error disclosure including emotional tư vấn to patients, families & clinicians involved in serious medical errors. http://www.macoalition.org/documents/respondingToAdverseEvents.pdf


Benner, P.., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A Gọi for radical transformation. San Francisteo, CA: Jossey Bass.

Durmê man, C. F., & Sherwood, G. (2008). Educational approaches lớn bridge the chất lượng gap. Journal of Urongắn gọn xúc tích Nursing, 28, 431438

Kardong-Edgren, S., Adamson, K. A., Fitzgerald, C. (2010). A Reviews of Currently Published Evaluation Instruments for Human Patient Simulation. Clinical Simulation in Nursing  6(1), p. e25-e35

Marx, D. (2007a). Just Culture Training for Health Care Managers.Plano, TX: Outcome Engineering, LLC.

Marx, D. (2007b), Patient Safety & the “Just Culture”. Plano, TX: Outcome Engineering, LLC. http://www.health.ny.gov/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf

Sherwood, G. & Barnsteiner, J. (2012). Quality và Safety in Nursing: A competency approach khổng lồ improving outcomes. Hoboken, NJ: Wiley-Blackwell.

Sullenberger III, C. B. & Zaslow, J. (2009). Highest Duty, Thủ đô New York, NY: HarperCollins e-books.

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After you have sầu reviewed the module presentations và resources, consider how this material is relevant to your own work and experience. The following is a danh mục of questions for self-reflection or for use in discussions with colleagues.

Reflecting upon courses in your curriculum, how vày learners experience teamwork và collaboration? Are there experiences learners currently have sầu that could be tweaked to lớn be interprofessional?What are the barriers we face in preparing learners to lớn understvà error, near misses and the role communication & collaboration have on the unique and safety of patient care? How might we create ways to lớn weave safety & communication and teamwork immersive sầu experiences into our courses?What’s one thing I could try in my class tomorrow that would help my learners appreciate the issues around patient safety and errors?What strategies have you already tried in the courses you teach that help learners understvà patient safety, errors và their role in creating a culture of safety?