enhancing safety and improving the “blunt end” or care.
To prepare nursing students to function in the complex health care environment. The QSEN project was established. The QSEN Institute is a collaborative of healthcare professionals focused on education, practice, and scholarship to improve the quality and safety of health care systems. Their goal is to prepare future nurses at the baccalaureate and graduate levels with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the health care systems within which they work. Based on earlier work completed by the Institute of Medicine (2001), QSEN identified six core competencies for new graduates, as outlined in Table 4.4 (QSEN, 2018). Each core competency is described below. The competencies are used to frame this chapter's discussion of high reliability.
Table 4.4 QSEN Competencies
| Patient‐Centered Care |
| Teamwork and Collaboration |
| Evidence‐based Practice (EBP) |
| Quality Improvement (QI) |
| Safety |
| Informatics |
Source: QSEN.org.
Patient‐Centered Care
In this competency, nurses recognize that the patient or designee is the source of control. Patients are full partners when the nurse is providing compassionate and coordinated care. Patients identify their designees, typically family members or close friends. Nurses respect the preferences, values, and needs of their patients and the way in which patients define family.
The relationship between direct patient care and patient‐centered care is easy to understand. In addition, nurses and nurse leaders must consider patients and their designees in a broader context. Nurse leaders must create organizational cultures that assess and support patient and family preferences. They must use current evidence when designing patient care areas to promote patient‐centered care. Nurse leaders must also work within their institutions to remove barriers to the presence of families and their designees. Establishing a Patient Family Advisory Committee can be helpful in providing input for nurse leaders and other organizational leadership. Patient‐centered care is discussed in greater detail in Chapter 8.
Case Study 4.1
Providing patient‐centered care is an important part of building a high reliability culture. Chris, a nurse on the Pediatric ICU, is caring for a 3‐month‐old with a history of supraventricular tachycardia, cough, and congestion. Chris reviews the patient's EHR and finds an order for Propranolol 20 mg TID. As an experienced pediatric nurse, Chris realizes this dose is high. She knows pediatric doses are weight‐based and consults a drug reference book to determine the appropriate dose. Chris also talks with the mother and learns that the infant was taking 2 mg of Propranolol three times a day at home. She then speaks to the physician, who changes the medication order and thanks Chris for her diligence.
1 Why did Chris consult a drug reference book?
2 Why did Chris talk with the patient's mother?
3 How might Chris best present this information to the physician?
4 How does Chris's diligence and the thank you from the physician help to build a culture of high reliability?
In this scenario, Chris took two positive safety actions: she demonstrated a questioning attitude while providing patient care, and she involved the patient's mother in his investigation. Chris carefully considered the patient care situation and asked herself some key questions. Is this what I expected to see? Does this fit with what I know? Does this make sense to me? She then investigated by checking with independent, expert sources, competent people, and written materials that could help resolve the question.
Teamwork and Collaboration
In this competency, nurses function effectively within both nursing and interprofessional teams. They foster open communication, mutual respect, and shared decision‐making to achieve quality patient care. This needs to happen at every level of the organization. Direct care nurses must function within their scope of practice and integrate the contributions of others to help patients achieve health outcomes. Nurses must communicate effectively with the nursing team and with many other clinicians to enhance patient care and minimize risks associated with handoffs. Nurse leaders must lead or participate in the design and implementation of systems that support effective teamwork. They must create an organization that appreciates and values clear communication. Several strategies for enhancing communication are described below.
Effective Communication
Improving the effectiveness of communication among caregivers is one of the National Patient Safety Goals (TJC, 2018a, 2018b, 2018c). Communication ensures that messages are heard correctly and accurately; prevents incorrect assumptions and misunderstandings that could lead to wrong decisions; and is essential within nursing and with other members of the interprofessional team.
TeamSTEPPS
TeamSTEPPS ® (AHRQ, 2013a, 2013b) provides several tools for improving communication, including call‐out and closed‐loop (or three way) communication.
Call‐Out
Call‐Out is a tool used to communicate important information. It informs all team members simultaneously during an emergency and helps team members anticipate next steps. For example, during a code, the nurse uses a call‐out to report “I've administered 1 mg Epinephrine IV.”
Closed Loop Communication
Closed loop communication ensures that the message received is the same as what was intended by the sender. The sender initiates communication with a receiver by providing a request, information, or clinician order. The receiver acknowledges the communication with a repeat‐back. The sender then confirms the accuracy of the acknowledgement by saying “that's correct.” If communication isn't clear, the nurse must clear up the confusion. “Let me ask a clarifying question” is a helpful and non‐threatening phrase to use when attempting to clarify communication.
Case Study 4.2
Sam is a nurse on a medical‐surgical unit. When he receives a telephone order from a physician, he enters it into the EHR and reads it back to the physician. Sam waits for the physician to verify the order before concluding the conversation. Sam also uses closed‐loop communication when communicating with or delegating to a nursing assistant.
1 Why does Sam read back the telephone order to the physician?
2 What factors may tempt Sam to skip this important safety step?
3 How does closed‐loop communication between Sam and a nursing assistant build strong teams and foster patient safety?
