Is technology used to enhance safety?4 Review the chapter content related to the Science of Human Error. Why is it important to know if the error is skill‐based, rule‐based, or knowledge‐based? Which types of errors have you made, in your personal or professional life? What tools would help prevent these errors?
5 Review the chapter content related to the I PASS the BATON and SBAR communication tools. The next time you are providing care, try using one of these tools in your handoff to another provider. Did the tool help you to organize your thoughts more concisely? Did it prompt you to share the most pertinent information?
6 The government and other organizations are mandating public reporting for health care safety, quality, and financial indicators. How does this transparency influence quality and safety? What nursing resources are available to assist a health care organization on the road to high reliability? What interprofessional resources are available?
DISCUSSION POINTS
1 During your last clinical experience, how was quality nursing care visible?
2 What types of quality initiatives were visible on the nursing unit?
3 What quality improvement models were used in the institution?
4 How does the culture of a hospital affect nurse involvement with quality improvement projects?
5 How can you improve quality and safety as a direct care nurse?
DISCUSSION OF OPENING SCENARIO
1 What factors may have contributed to the original error?
2 Why was an interprofessional team convened for the root cause analysis?
3 What factors may have contributed to a second error in the pediatric department?
4 Both human factors and organizational factors may have contributed to this error. The nurse may have been fatigued or rushed. She may not have treated the breast milk like a medication, and may not have checked the table three times. The nurse may have experienced confirmation bias, seeing what she expected to see. The nurse may have read the label correctly but reached for the wrong container. The label may have been handwritten and difficult to read. The room may have been poorly lit, making it difficult to read the label. Breast milk storage may not have been individualized for each patient, making it easy to grab the wrong container. The organization may not have invested in bar code scanning technology.
5 Although on the surface this appears to be a simple nursing error, as seen above, many factors may have contributed to the error. All stakeholders should be involved in a root cause analysis to provide a broad perspective and create the most effective plan for preventing the error in the future.
6 Organizational culture, communication, and human factors may allow the same error to occur in different areas within the same organization. If an organization lacks transparency, lessons learned from errors in one area are not shared with other areas. They are kept “secret.” Even if an organization aspires to transparency, communication must be clear, concise, and targeted so that the information is received and perceived to be important by the clinicians who may be affected. Nurses and other clinicians must realize they, too, are vulnerable to making errors. The attitude of “I would never make that mistake” needs to be expunged.
EXPLORING THE WEB
1 www.ahrq.gov, to review an Agency for Healthcare Improvement Patient Safety Survey tool, Accessed August 28, 2019.
2 www.medicare.gov/hospitalcompare/search.html, to compare hospital quality performance, Accessed August 28, 2019.
3 https://ww2.mc.vanderbilt.edu/crew_training for Vanderbilt Crew Training information, Accessed August 28, 2019.
4 http://qsen.org to review QSEN competencies for undergraduate and graduate nurses, Accessed August 28, 2019.
5 https://nursingworld.org to see nursing's position on culture of safety and just culture, Accessed August 28, 2019.
INFORMATICS
Go to the website for the Centers for Medicare and Medicaid Hospital Compare, www.medicare.gov/hospitalcompare/search.html. Accessed August 28, 2019. Enter several hospitals located close to your zip code. Review the ratings. What are their strengths? Where do they have opportunities to improve their safety?
LEAN BACK
What do you see in practice that is different from what you read in this chapter? Why do you think these differences exist?
How does the information from this chapter influence you as a nursing student?
How do you think you will use this chapter's information to change practice as a nurse?
How much or how little do you think this chapter's information will matter to you as a nurse leader?
REFERENCES
1 Academy of Medical‐Surgical Nurses. (2019). Nurse resiliency. Retrieved from www.amsn.org/practice-resources/healthy-practice-environment/nurse-resiliency
2 Agency for Healthcare Research and Quality. (2013a). Agency for Healthcare Research and Quality (AHRQ). www.ahrq.gov
3 Agency for Healthcare Research and Quality. (2013b). TeamSTEPPS pocket guide. Retrieved from www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.pdf
4 Agency for Healthcare Research and Quality. (2017). Surveys on patient safety cultureTM. Retrieved from www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
5 Agency for Healthcare Research and Quality. (2018a). Patient Safety Network. Root cause analysis. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis
6 Agency for Healthcare Research and Quality. (2018b). Patient Safety Network: High reliability. Retrieved from https://psnet.ahrq.gov/primers/primer/31/high-reliability
7 Agency for Healthcare Research and Quality. (n.d.). Patient safety organization (PSO) program: Federally‐listed PSOs. Retrieved from www.pso.ahrq.gov/listed
8 American Association of Critical Care Nurses. (2014). ICU nurses benefit from resilience training. Retrieved from www.aacn.org/newsroom/ajcc-resilience-research
9 American Association of periOperative Nurses. (2018). AORN: Safe surgery together. Retrieved from www.aorn.org
10 American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from https://www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf
11 American Nurses Association. (2010). Position statement: Just culture. Retrieved from https://nursingworld.org/psjustculture
12 American Nurses Association. (2016). Culture of Safety. Retrieved from www.nursingworld.org/practice-policy/work-environment/health-safety/culture-of-safety
13 American
