N 336 M2 W5: EBP & Research

Dr. Whitney Bischoff, Associate Professor of Nursing, TLU

Module Objectives

    1. Explain evidence based practice in the context of healthcare.
    2. Explain the impact of quality & safety initiatives on delivery of healthcare.

    Learning Activities

    Read: Sultz and Young Chapter 12 Pozgar: pgs 99-106; 255-298
    • Landmark Nursing Research Studies (link below)

    Watch videos: Chasing Zero Medical Error Reporting System (below)

    Answer Discussion Questions under Module Discussions (RN-BSN Cohort)

    Take Quiz 12 in Assignments (optional)
    Chasing Zero: Winning the War on Healthcare Harm
    Event Reporting and Patient Safety:

    Transcript for MERS video

    Published on May 17, 2016

    TO USE OR PRINT this presentation click : http://videosliders.com/r/1165

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    Event Reporting and Patient Safety: You Can’t fix it If You Don’t Know About it! Harold S. Kaplan MD Columbia University hsk18@columbia.edu Supported by an NHLBI RO1 Grant for Event Reporting System in Transfusion Medicine
    ,“To Err is Human “Institute of Medicine Report1999 Identify and learn from errors through reporting systems — both mandatory and voluntary.


    ,Congressional Action Senate Bill 2038 - Medical Error Reduction Act of 2000
    Senate Bill 2378 - Stop All Frequent Errors (SAFE) Patient Safety Improvement Act -(Kennedy) Voluntary, non-punitive environment to share safety information without fear of reprisal ,Interest in Other Countries Great Britain- An Organization with a Memory
    Report of the chief medical officer on learning from adverse events in the National Health Service
    Australia - The Quality in Australian Heath Care Study ,Ubiquitous Calls for Reporting Systems Kennedy bill
    IOM report JCAHO 15 States and counting Illinois


    ,Types of Events MERS-TM is designed to capture all types of events.


    ,Heinreich’s Ratio1 It has been proposed that reporting systems could be evaluated on the proportion of minor to more serious incidents reported 2 1 Major injury
    29 Minor injuries 300 No-injury accidents 1 29 300 1. Heinreich HW Industrial Accident Prevention, NY And London 1941 2. An Organization With a Memory, A report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer, The Stationary Office, London 2000


    ,Misadventures The event actually happened and some level of harm — possibly death — occurred.


    ,No Harm Events The event actually occurred but no harm was done.


    ,Near Miss Events The potential for harm may have been present, but unwanted consequences were prevented because some recovery action was taken.


    ,Misadventure Return to Normal Technical Failure Near Miss Yes Adequate Defenses? Human Error Dangerous Situation Yes No Adequate Recovery? Developing Incident Organizational Failure No Van der Schaaf’s Incident Causation Model


    ,Recovery — planned or unplanned Study of recovery actions is valuable. Planned recovery built into our processes
    Unplanned recovery lucky catches


    ,Six-Year Old Killed by Flying O2 Cylinder in MRI Suite A Unique “one-off” event?
    VA experience FDA and other reports Near misses unlikely to be reported


    ,Near Misses Or No Harm Events With MRI When workers dismantled an MRI machine recently at the University of Texas, they discovered dozens of pens, paper clips, keys and other metal objects clustered inside. ...


    ,Purpose of an Event Reporting System Useful data base to study system’s failure points
    Many more near misses than actual bad events Source of data to study human recovery Dynamic means of understanding system operations


    ,Types of Errors Active— are errors committed by those in direct contact with the human-system interface (human error)
    Latent—are the delayed consequences of technical and organizational actions and decisions ,Types of Errors  Active Errors
    Skill based
    Rule based Knowledge based Latent Errors (conditions or failures) Technical
    Organizational Other (patient/donor related and “other”) ,Skill-based Error Failure in the performance of a routine task that normally requires little conscious effort Example — locking your keys in the car because you’re distracted by someone calling your name


    ,Rule-based Error Failure to carry out a procedure or protocol correctly or choosing the wrong rule Example — not waiting your turn at a 4-way stop sign


    ,Knowledge-based Error Failure to know what to do in a new situation (problem solving at conscious level) Example —not knowing what to do when the traffic light is out


    ,Types of Errors Active Errors
    Skill based
    Rule based Knowledge based Latent Errors (conditions or failures) Technical
    Organizational Other (patient/donor related and “other”)

    When you have finished the assigned learning activities, go on to the next lesson.