Quality Assurance
Director of Quality, Medical Staff & Graduate Medical Education
Chasity Garman BSN, RN
Patient found down on floor during hourly rounding. This is
Unwitnessed Fall
a localized area of skin and underlying tissue damage caused by unrelieved pressure, friction, or shear forces, often occurring over bony prominences.
Pressure Injury
name of report released addressing medical errors and the needs for a safer healthcare delivery system
To Err is Human
a patient being readmitted to a hospital within 30 days of their previous discharge, regardless of the reason for the readmission.
"All Cause" Readmission
the process of enhancing the effectiveness, efficiency, or quality of something
Performance Improvement
Must be completed by nursing leadership, primary RN and care team following each fall
"Post-Fall Huddle"
Wound Prevention Coordinator
Mary Wolphagen RN
Name the three main types of medical errors
1. Diagnostic
2. Treatment
3. Prevention
process by which CMC Quality Team reviews processes and workflows as well as documentation related to patient care to ensure quality standards are being met and that patient safety standards are being maintained
Internal Audits
a systematic process focused on preventing and correcting errors to ensure that services meet or exceed established standards of quality and expectations
Quality Assurance
risk assessment tool to be completed once per shift and PRN
Morse Fall Risk Assessment
a database maintained by Press Ganey that collects and analyzes data related to nursing care quality in hospitals; maintains prevalence data on pressure injuries
NDNQI
the failure to accurately and promptly identify a patient's health problem or to effectively communicate that explanation to the patient
Diagnostic Error
a value based purchasing program established by the Affordable Care Act that incentivizes hospitals to reduce readmissions
Hospital Readmissions Reduction Program (HRRP)
This approach involves making small, incremental changes based on data to improve a process.; often used as a performance improvement process
Plan Do Study Act
(PDSA Cycle)
Elements of Fall Prevention Bundle (Nursing Interventions)
Acceptable Responses:
Yellow Socks, Yellow Wrist Band, Hourly Rounding, Call Light in Reach, Bed Locked in Low Position, Bed Alarm On, Etc.
the proportion of inpatient hospitalizations for patients aged 18 and older who develop a new Stage 2, Stage 3, Stage 4, Deep Tissue, or Unstageable pressure injury while under the hospital's care.
eCQM: Hospital Harm - Pressure Injury
a health professional fails to complete a planned action or treatment as it was intended, or uses an incorrect plan for an action or treatment
Treatment Error
a serious, unexpected occurrence involving death, severe physical or psychological injury, or the risk thereof, in a healthcare setting.
Sentinel Event
A systematic process used to investigate adverse events, near misses, and other significant problems to identify the underlying causes and prevent future occurrences. It moves beyond assigning blame to individuals and instead focuses on identifying system-level failures that contributed to the event.
Root Cause Analysis (RCA)
True or False?: A fall with a hip fracture that ultimately results in death due to secondary complications is reportable outside of CMC?
True
Estimated prevalence of HAPI's following a meta-analysis
8.4%
an event or situation where a medical error or adverse event is narrowly avoided, requiring follow up investigation and incident reporting
Near Miss
Name the 3 Red Rules outlined in "CMC Policy ADM-5.22-POL “Safety Responsibility: Red Rule Policy""
1. Patient Identification
2. Surgical Time Out
3. Specimen Labeling