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chapter 10 | Quality and Safety 143 CikguOnline
within the organization must be made aware of imperative.The main goal is patient safety.Reporting
the event; they must investigate and understand and remediation must occur quickly (Huber, 2000).
the causes of the event; and they must make Once an incident has occurred, you must com-
changes in the organization’s systems and plete an incident report immediately. The incident
processes to reduce the probability of such an report is used to collect and analyze data for future
event in the future (jcaho.org/ptsafety_frm.html). determination of risk. The report should be accu-
rate, objective, complete, and factual. If there is
The subset of sentinel events that is subject to
future litigation, the plaintiff’s attorney can sub-
review by JC includes any occurrence that meets
poena the report. The report should be prepared in
any of the following criteria:
only a single copy and never placed in the medical
■ The event has resulted in an unanticipated death record (Swansburg & Swansburg, 2002). It is kept
or major permanent loss of function, not related with internal hospital correspondence.
to the natural course of the patient’s illness or Nurses have a responsibility to remain educated
underlying condition. and informed and to become active participants in
■ The event is one of the following (even if the out- understanding and identifying potential risks to
come was not death or major permanent loss of their patients and to themselves. Ignorance of the
function): suicide of a patient in a setting where law is no excuse. Maintaining a knowledgeable,
the patient receives around-the-clock care (e.g., professional, and caring nurse-patient relationship
hospital, residential treatment center, crisis is the first step in decreasing your own risk.
stabilization center), infant abduction or discharge
to the wrong family, rape, hemolytic transfusion The Economic Climate
reaction involving administration of blood or in the Health-Care System
blood products having major blood group incom-
patibilities, surgery on the wrong patient or
For many years, decisions about care were based
wrong body part (jcaho.org/ptsafety_frm.html)
primarily on providing the best quality care, what-
ever the cost. As the economic support for health
Adhering to nursing standards of care as well as the
care is challenged, however, health-care providers
policies and procedures of the institution greatly
are pressured to seek methods of care delivery that
decreases the nurse’s risk. Common areas of risk for
achieve quality outcomes at lower cost.
nursing include:
■ Medication errors Economic Perspective
■ Documentation errors and/or omissions The economic perspective is rooted in three funda-
■ Failure to perform nursing care or treatments mental observations:
correctly
1. Resources are scarce. Due to scarce resources,
■ Errors in patient safety that result in falls
three choices result:
■ Failure to communicate significant data to
patients and other providers (Swansburg & ■ The amount to be spent on health-care services
Swansburg, 2002) and the composition of those services
■ The methods for producing those services
Risk management programs also include attention
■ The method of distribution of health care,
to areas of employee wellness and prevention of
which influences the equity with which these
injury. Latex allergies, repetitive stress injuries,
services are distributed
carpal tunnel syndrome, barrier protection for
tuberculosis, back injuries, and the rise of antibiotic- 2. Resources have alternative uses. As a result of
resistant organisms all fall under the area of risk this scarcity, the choice to expend resources in
management (Huber, 2000). one area eliminates the use of those same
Adhering to standards of care and exercising the resources in another area. If more nursing
amount of care that a reasonable nurse would homes are going to be built, for example, then
demonstrate under the same or similar circumstances there will be fewer hospitals, less housing, less
can protect the nurse from litigation. Understanding education, or other uses of those same
what actions to take when something goes wrong is resources.