# 1
Opportunities & Challenges with Patient Safety Goals
Annerys Velazco
St. Thomas University
NUR 415 AP 1
Dr. Rosa Rousseau
08/04/22
The Joint Commission established the National Patient Safety Goals in 2003 as a program to promote quality and patient safety. The NPSGs were developed to assist accredited organizations in addressing specific patient safety concerns. The selected 2022 NPSG for this study is Goal 3: improving the safety of using medications (NPSG.03.04.01). In perioperative and other procedural settings, all drugs should be labeled, including medication containers, and other solutions on and off the sterile field. In this case, medication containers include syringes, medicine cups, and basins. In the clinical settings, the unlabeled medications and other solutions are usually unidentifiable. As a result, errors, sometimes fatal, have occurred as a result of drugs and other solutions being removed from their original containers and placed in unlabeled containers (Larmené-Beld et al., 2018). This dangerous practice is a direct violation of the basic principles of safe medication administration, and yet, it is common practice in many workplaces. Therefore, this NPSG goal ensures that there is labeling of all pills, medication containers, and other solutions in a process that is risk-reducing and is much compatible with good medication management practices. Further, the goal addresses a known danger point in the delivery and administration of drugs in perioperative and other procedural settings.
To fully achieve this goal there are various elements of performance that need to be achieved. First, the healthcare provider has to label drugs and solutions that are not immediately provided in the perioperative and other procedural settings. This is true even if only one medicine is utilized. According to Bowdle et al. (2018), in the sterile field today, the labelling errors usually involve the mixing of two liquids in labelled containers. As such, the approach that is necessary to prevent these errors, supported by 2022 NPSG goal 3, is straightforward and very simple and that is; correct and full labeling of all solution and drug containers on the sterile field in every procedural area, every time. The second element of performance is that labeling occurs in perioperative and other procedural settings on and off the sterile field when any medical solution is transferred from the original packing to another container. The basic function of a label in this case is to guarantee that healthcare provider and the patient can readily identify the medicine even if it has been placed in a new container. It is essential to note that, there may arise confusion between medications with similar names, labels, or packaging. This has been recognized as a major source of error among healthcare providers who administer medication to patients.
Overall, there has been many cases of medication errors that arise from poor labelling of drug containers whi ...
Running head McVeigh– Defensive Medicine Essay 1 1 .docxcowinhelen
Running head: McVeigh– Defensive Medicine Essay 1
1
It has been said that the fear of medical liability drives healthcare providers, particularly
physicians, to unnecessarily order diagnostic tests and to perform treatments and procedures
that may not be necessary, simply to ensure that nothing is left undone. Is this in fact the case?
Defend position on this premise using literature.
Langley McVeigh, MHA, FACHE
May 23, 2017
McVeigh - Defensive Medicine 2
Yes, defensive medicine is practiced in the United States. However, it is important to
understand: (1) what impact it has on healthcare expenditures (2) to what degree does it occur
(prevalence) and (3) if so, what can be done to prevent it?
As an emergency services administrator for a Level 1 trauma center, experience has led
me to understand the dynamic influencing physicians in their clinical decision making process.
Ideally, this process should be void of non-clinical bias or influence. However, this is not the
case in many circumstances. Physicians are considering risk and liability when ordering tests
and procedures. This risk management, or risk mis-management, phenomenon is called
defensive medicine. By definition, these occurrences are medical practices intended to
exonerate practitioners from liability with limited or without medical benefit to the patient
(Sethi et al, 2012). Physicians have been directed by health policy to provide value based care,
but defensive medicine practice works against this care model.
There have been studies conducted measuring physician attitudes towards tort reform
and defensive medicine practices. While studies show physicians, especially high risk medical
specialists, regularly practicing defensive medicine, the cost implications are unclear.
Furthermore, proposed reforms to the medical tort system must be investigated. Some have
proposed to completely do away with the medical tort litigation and insurance system,
replacing it with a system similar to workman’s compensation models. While it may be a reflex
mechanism to use cost as a metric to measure results of defensive medicine practices, patient
outcomes and quality of life implications must also be measured. The patient is the one who is
being subjected to additional and unwarranted procedures.
McVeigh - Defensive Medicince 3
According to a survey of 2000 orthopedic surgeons in 2010 (Sethi et al, 2012), of the
1214 respondents, 96% admitted to have practiced defensive medicine by ordering labs,
imaging studies, specialist referrals, and inpatient admissions. Many surgeons confided this was
done to avoid malpractice claims. These prescriptions offered little no benefit to patient
outcomes, and contrary to the current posture of value based practice in our health care
system. This additional intervention is costly, at an inconvenience to the patient, and may carry
additional health risk. As a reflex, one may think of ...
This document discusses issues with patient misidentification in healthcare and proposes solutions. It notes that patient misidentification can lead to medical errors and harm patients. Interventions like using two patient identifiers, barcoding systems, and staff education on safety protocols may help reduce errors related to improper identification. The importance of ensuring patients receive the correct treatments and medications is emphasized.
Introduction Healthcare system is considered one of the busiest.pdfbkbk37
The document discusses the application of clinical information systems in nursing. It reviews 4 peer-reviewed articles on the topic. The articles found that clinical information systems can improve workflow and reduce medical errors. However, challenges remain around data integration and sharing patient data across healthcare systems. The document concludes that clinical systems provide opportunities to improve care if effectively implemented and regularly updated to support nurses.
NURS 521 Nursing Informatics And Technology.docxstirlingvwriters
This document discusses the application of clinical information systems in nursing. It reviews 4 peer-reviewed articles on this topic. The articles found that clinical information systems can help reduce medical errors, improve care quality by enhancing workflow and access to patient information, and engage patients more in their care when interactive technology is used. However, challenges remain around data integration across healthcare systems and technical, human, and organizational constraints. The document concludes that clinical information systems provide opportunities to improve care but must be effectively implemented and upgraded so nurses can benefit from these technologies.
April 2012 Volume 19 Number 1 NURSING MANAGEMENT32Feat.docxrossskuddershamus
April 2012 | Volume 19 | Number 1 NURSING MANAGEMENT32
Feature Feature
EstimatEs of the number of americans who
die annually from preventable medical errors are
astonishingly high, with studies citing figures of
between 44,000 and 98,000 (american Hospital
association 1999, Kohn et al 2000). as a result,
Us consumer and regulatory bodies have dedicated
considerable human and financial resources
to ameliorating the problem by setting standards
to promote and ensure safety and to mitigate errors.
the Us healthcare industry has, in addition,
entered an era of transparency, with publicly
reported quality and patient safety data, and is
no longer reimbursed for costs associated with
certain preventable or hospital-acquired conditions.
in the coming years, through provisions
made by the Centers for medicare and medicaid
services (Cms) and the recently enacted Patient
Protection and affordable Care act, Us hospitals
will be under pressure to address safety and
quality issues. Reimbursement for hospital care
will diminish and fines will be imposed for not
meeting specified, predetermined quality indicators
(Cromwell et al 2011).
a major movement to encourage institutions
to shift towards a non-punitive and fair culture
of safety and zero errors is gathering momentum.
it is led by several national organisations that
include the Committee on Quality of Health
Care in america/institute of medicine of the
National academies, the institute for Healthcare
improvement and the Us Department of Health and
Human services agency for Healthcare Research
and Quality.
Central to this movement is the incorporation
of strategies developed in the aviation industry,
which include using checklists to foster and ensure
safe practice.
Numerous examples illustrate the success of
checklists in preventing individual episodes of
harm and even fatalities, such as the World Health
organization’s surgical safety Checklist (2009) and
the Checklist manifesto (Gawande 2009). However,
healthcare providers, and nurses in particular,
must be encouraged to look not only at how
checklists are increasingly used in daily practice,
but also how they present a subtle yet requisite
context for ethical decision making. failure to
examine the ethical dimension of such routine
activities may perpetuate rather than prevent unsafe
practices or errors occurring.
Nursing documentation
Documentation is a significant component of
nurses’ daily practice and serves as ‘one important
mechanism used to evaluate care performance
conducted by the caregiver serving as the centre of
nursing activities’ (Cheevakasemsook et al 2006).
Ethics of everyday decision making
Gina Kearney and Sue Penque discuss the responsibility of staff
to document care accurately. Using the example of checklists,
they show how simple omissions can put patient safety at risk
abstract
Evidence suggests that checklists can prevent
episodes of patient harm and they ar.
The Increasing Importance of Patient Reported Outcomes and the Patient Voice ...Covance
Over the past few years there has been a paradigm shift in the overall approach to pharmacovigilance from that of pure safety analysis to overall benefit-risk evaluation of products. **Disclaimer: This article was previously published. Sciformix is now a Covance company.
Article Type: Editorial
Title: Patient Safety: Paradigm shift of modern healthcare delivery and research
Year: 2022; Volume: 2; Issue: 1; Page No: 1 – 2
Author: Dr. Mohammed Imran
10.55349/ijmsnr.20222112
Affiliation: Associate Professor, Medical Pharmacology, College of Medicine and Health Sciences, Sohar, National University of Science and Technology, Sultanate of Oman.
Email ID: imran@nu.edu.om
Article Summary:
Submitted : 10-February-2022
Revised : 26-February-2022
Accepted : 12-March-2022
Published : 31-March-2022
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
Running head McVeigh– Defensive Medicine Essay 1 1 .docxcowinhelen
Running head: McVeigh– Defensive Medicine Essay 1
1
It has been said that the fear of medical liability drives healthcare providers, particularly
physicians, to unnecessarily order diagnostic tests and to perform treatments and procedures
that may not be necessary, simply to ensure that nothing is left undone. Is this in fact the case?
Defend position on this premise using literature.
Langley McVeigh, MHA, FACHE
May 23, 2017
McVeigh - Defensive Medicine 2
Yes, defensive medicine is practiced in the United States. However, it is important to
understand: (1) what impact it has on healthcare expenditures (2) to what degree does it occur
(prevalence) and (3) if so, what can be done to prevent it?
As an emergency services administrator for a Level 1 trauma center, experience has led
me to understand the dynamic influencing physicians in their clinical decision making process.
Ideally, this process should be void of non-clinical bias or influence. However, this is not the
case in many circumstances. Physicians are considering risk and liability when ordering tests
and procedures. This risk management, or risk mis-management, phenomenon is called
defensive medicine. By definition, these occurrences are medical practices intended to
exonerate practitioners from liability with limited or without medical benefit to the patient
(Sethi et al, 2012). Physicians have been directed by health policy to provide value based care,
but defensive medicine practice works against this care model.
There have been studies conducted measuring physician attitudes towards tort reform
and defensive medicine practices. While studies show physicians, especially high risk medical
specialists, regularly practicing defensive medicine, the cost implications are unclear.
Furthermore, proposed reforms to the medical tort system must be investigated. Some have
proposed to completely do away with the medical tort litigation and insurance system,
replacing it with a system similar to workman’s compensation models. While it may be a reflex
mechanism to use cost as a metric to measure results of defensive medicine practices, patient
outcomes and quality of life implications must also be measured. The patient is the one who is
being subjected to additional and unwarranted procedures.
McVeigh - Defensive Medicince 3
According to a survey of 2000 orthopedic surgeons in 2010 (Sethi et al, 2012), of the
1214 respondents, 96% admitted to have practiced defensive medicine by ordering labs,
imaging studies, specialist referrals, and inpatient admissions. Many surgeons confided this was
done to avoid malpractice claims. These prescriptions offered little no benefit to patient
outcomes, and contrary to the current posture of value based practice in our health care
system. This additional intervention is costly, at an inconvenience to the patient, and may carry
additional health risk. As a reflex, one may think of ...
This document discusses issues with patient misidentification in healthcare and proposes solutions. It notes that patient misidentification can lead to medical errors and harm patients. Interventions like using two patient identifiers, barcoding systems, and staff education on safety protocols may help reduce errors related to improper identification. The importance of ensuring patients receive the correct treatments and medications is emphasized.
Introduction Healthcare system is considered one of the busiest.pdfbkbk37
The document discusses the application of clinical information systems in nursing. It reviews 4 peer-reviewed articles on the topic. The articles found that clinical information systems can improve workflow and reduce medical errors. However, challenges remain around data integration and sharing patient data across healthcare systems. The document concludes that clinical systems provide opportunities to improve care if effectively implemented and regularly updated to support nurses.
NURS 521 Nursing Informatics And Technology.docxstirlingvwriters
This document discusses the application of clinical information systems in nursing. It reviews 4 peer-reviewed articles on this topic. The articles found that clinical information systems can help reduce medical errors, improve care quality by enhancing workflow and access to patient information, and engage patients more in their care when interactive technology is used. However, challenges remain around data integration across healthcare systems and technical, human, and organizational constraints. The document concludes that clinical information systems provide opportunities to improve care but must be effectively implemented and upgraded so nurses can benefit from these technologies.
April 2012 Volume 19 Number 1 NURSING MANAGEMENT32Feat.docxrossskuddershamus
April 2012 | Volume 19 | Number 1 NURSING MANAGEMENT32
Feature Feature
EstimatEs of the number of americans who
die annually from preventable medical errors are
astonishingly high, with studies citing figures of
between 44,000 and 98,000 (american Hospital
association 1999, Kohn et al 2000). as a result,
Us consumer and regulatory bodies have dedicated
considerable human and financial resources
to ameliorating the problem by setting standards
to promote and ensure safety and to mitigate errors.
the Us healthcare industry has, in addition,
entered an era of transparency, with publicly
reported quality and patient safety data, and is
no longer reimbursed for costs associated with
certain preventable or hospital-acquired conditions.
in the coming years, through provisions
made by the Centers for medicare and medicaid
services (Cms) and the recently enacted Patient
Protection and affordable Care act, Us hospitals
will be under pressure to address safety and
quality issues. Reimbursement for hospital care
will diminish and fines will be imposed for not
meeting specified, predetermined quality indicators
(Cromwell et al 2011).
a major movement to encourage institutions
to shift towards a non-punitive and fair culture
of safety and zero errors is gathering momentum.
it is led by several national organisations that
include the Committee on Quality of Health
Care in america/institute of medicine of the
National academies, the institute for Healthcare
improvement and the Us Department of Health and
Human services agency for Healthcare Research
and Quality.
Central to this movement is the incorporation
of strategies developed in the aviation industry,
which include using checklists to foster and ensure
safe practice.
Numerous examples illustrate the success of
checklists in preventing individual episodes of
harm and even fatalities, such as the World Health
organization’s surgical safety Checklist (2009) and
the Checklist manifesto (Gawande 2009). However,
healthcare providers, and nurses in particular,
must be encouraged to look not only at how
checklists are increasingly used in daily practice,
but also how they present a subtle yet requisite
context for ethical decision making. failure to
examine the ethical dimension of such routine
activities may perpetuate rather than prevent unsafe
practices or errors occurring.
Nursing documentation
Documentation is a significant component of
nurses’ daily practice and serves as ‘one important
mechanism used to evaluate care performance
conducted by the caregiver serving as the centre of
nursing activities’ (Cheevakasemsook et al 2006).
Ethics of everyday decision making
Gina Kearney and Sue Penque discuss the responsibility of staff
to document care accurately. Using the example of checklists,
they show how simple omissions can put patient safety at risk
abstract
Evidence suggests that checklists can prevent
episodes of patient harm and they ar.
The Increasing Importance of Patient Reported Outcomes and the Patient Voice ...Covance
Over the past few years there has been a paradigm shift in the overall approach to pharmacovigilance from that of pure safety analysis to overall benefit-risk evaluation of products. **Disclaimer: This article was previously published. Sciformix is now a Covance company.
Article Type: Editorial
Title: Patient Safety: Paradigm shift of modern healthcare delivery and research
Year: 2022; Volume: 2; Issue: 1; Page No: 1 – 2
Author: Dr. Mohammed Imran
10.55349/ijmsnr.20222112
Affiliation: Associate Professor, Medical Pharmacology, College of Medicine and Health Sciences, Sohar, National University of Science and Technology, Sultanate of Oman.
Email ID: imran@nu.edu.om
Article Summary:
Submitted : 10-February-2022
Revised : 26-February-2022
Accepted : 12-March-2022
Published : 31-March-2022
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, DioneWang844
MHA6999 SEMINAR IN HEALTHCARE CASES-- WEEK 2 LECTURE, DISCUSSION, AND PROJECT INSTRUCTIONS
Page | 1
Quality
Nearly fifteen years ago, the Institute of Medicine published the “To Err Is Human” report, which exposed the substantial impact of medical errors in the US healthcare system and called for a dramatic system change, including an improved understanding of those errors (McCarthy, Tuiskula, Driscoll, & Davis, 2017). Medical errors are considered to be failure to achieve the original goal or plan of action, and these errors may range from a patient falls to a mistake in the operating room. Not only do medical errors cause harm to the patient and jeopardize the patient’s trust, but they also cause a financial strain for the health system (“To Err is Human,” 1999). One of the contributing factors to medical errors is the lack of effective communication between doctors who are treating the same patient. This results in healthcare providers overprescribing medications for patients as well as increases the possibility of a patient having unnecessary tests or procedures performed. The report’s four-tiered approach includes:
· Focusing on creating a stronger foundation of education on patient safety
· Mandating a nationwide reporting system to encourage timely reporting of errors
· Increasing the standards of performance for healthcare providers
· Taking advantage of the security that safety systems offer (“To Err is Human,” 1999)
Creating a strong educational foundation for patient safety is most important. Healthcare personnel are much more likely to actively participate in reporting systems, encourage one another to perform at a higher level, and take advantage of safety systems when they are well educated on patient safety and the implications of medical errors. The reporting system seems to provide the least amount of impact on patient safety as they can result in losing patient trust in certain healthcare systems. The healthcare system as a whole has made progress in establishing a safe environment for patients when they are in need of care.
Challenges for Patient Safety and Steps for Improvement
Despite continuing evidence of problems in patient safety and gaps between the care that patients receive and the evidence about what they should receive, efforts to improve quality in healthcare show mostly inconsistent and patchy results.
Tap each image to know more.
Data Collection and Monitoring Systems
This always takes much more time and energy than anyone anticipates. It is worth investing heavily in data from the outset. Assess local systems, train people, and have quality assurance.
Tribalism and Lack of Staff Engagement
Overcoming a perceived lack of ownership and professional or disciplinary boundaries can be very difficult. Clarify who owns the problem and solution, agree roles and responsibilities at the outset, work to common goals, and use shared language.
Convince People That There's a Problem
Use hard data to secure emotional e ...
INTEGRATING MACHINE LEARNING IN CLINICAL DECISION SUPPORT SYSTEMShiij
This review article examines the role of machine learning (ML) in enhancing Clinical Decision Support
Systems (CDSSs) within the modern healthcare landscape. Focusing on the integration of various ML
algorithms, such as regression, random forest, and neural networks, the review aims to showcase their
potential in advancing patient care. A rapid review methodology was utilized, involving a survey of recent
articles from PubMed and Google Scholar on ML applications in healthcare. Key findings include the
demonstration of ML's predictive power in patient outcomes, its ability to augment clinician knowledge,
and the effectiveness of ensemble algorithmic approaches. The review highlights specific applications of
diverse ML models, including moment kernel machines in predicting surgical outcomes, k-means clustering
in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
INTEGRATING MACHINE LEARNING IN CLINICAL DECISION SUPPORT SYSTEMShiij
This review article examines the role of machine learning (ML) in enhancing Clinical Decision Support
Systems (CDSSs) within the modern healthcare landscape. Focusing on the integration of various ML
algorithms, such as regression, random forest, and neural networks, the review aims to showcase their
potential in advancing patient care. A rapid review methodology was utilized, involving a survey of recent
articles from PubMed and Google Scholar on ML applications in healthcare. Key findings include the
demonstration of ML's predictive power in patient outcomes, its ability to augment clinician knowledge,
and the effectiveness of ensemble algorithmic approaches. The review highlights specific applications of
diverse ML models, including moment kernel machines in predicting surgical outcomes, k-means clustering
in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
Goal 1 improve the accuracy of patient identification.npsssuser47f0be
The document discusses patient identification and reducing errors related to misidentification. It focuses on using two patient identifiers, which can help reliably identify individuals and match them to the correct service or treatment. Newborns are at higher risk given their inability to communicate and lack of distinguishing features. The document provides examples of methods to prevent misidentification of newborns such as distinct naming systems and standardized identification banding practices.
The document discusses improving medication adherence and the complex landscape of issues involved. It notes that non-adherence results in high healthcare costs and negative health outcomes. Pharma companies are engaging with adherence issues due to business risks from lower sales and regulatory scrutiny. The landscape is complex with many patient, stakeholder, and systemic factors influencing adherence. Human-centered design and the transtheoretical model of behavior change are recommended approaches for developing well-targeted adherence solutions. Connected health technologies also show promise if designed with privacy, costs, and usability in mind.
Diabetes Management Policy Proposal
Miatta Teasley
Capella University
NHS-FPX6004 Health Care Law and Policy
Professor Georgena Wiley
May 19, 2022
Click to edit Master title style
Click to edit Master title style
Hello and welcome to today's presentation on drug error regulatory policy proposals. This presentation is intended to provide you, your stakeholders, with all pertinent information regarding the need for an institutional policy to reduce medication errors in medical centers. We will also go over the scope of the recommendations, strategies for addressing medication errors, and stakeholder involvement in putting these strategies into action.
Policy Proposal
Diabetes Management
2
Click to edit Master title style
Click to edit Master title style
This proposal revolves around creating and implementing strategies that will help Med’s caregivers be able to improve on patient care regarding diabetes.
Presentation Outline
Policy on Managing Medication Errors
Need for a Policy
Scope of Policy
Strategies to Resolve Mediation Errors
Role of the Hospital Staff
Positive impact on Working Conditions
Issues in the Application of Strategies
Alterative Perspectives on Mitigating Medication Errors
Stakeholder Participation
3
Click to edit Master title style
Click to edit Master title style
The presentation highlights key functions in any policy implementation process. The steps this presentation takes appear in the order as indicated here. We will start y looking at
Policy on Managing Medication Errors then
Need for a Policy followed by
Strategies to Resolve Mediation Errors. Then the
Role of the Hospital Staff and the
Positive impact on Working Conditions. Also, we will look at
Issues in the Application of Strategies and the
Alterative Perspectives on Mitigating Medication Errors and finally,
Stakeholder Participation
Policy on Managing Medication Errors
4
Health practitioners should create and advance engaging policies
Many Healthcare departments require modernization
Healthcare policies should be adjusted to meet defined benchmarks
Key stakeholders are vital for successful implementation of proposed policies
Click to edit Master title style
Click to edit Master title style
When advocating for organizational regulation changes about federal, state, or local health care guidelines or rules and regulations, healthcare practitioners should be able to create and advance an engaging and logical policy and guideline parameters that will provide a segment, a group, or an entire institution to correct and shed light on issues of accomplishment and execute developments in the quality and safety of medical management.
Despite being recognized as one of the greatest health insurance carriers for people over 65, several departments need to be modernized. The most pr.
Problem And Description Of Terms For DisseratationJenniferlaw1
This document summarizes a research study on medical malpractice and errors in the hospital system. The study investigated the lack of education and understanding of tort law among healthcare workers. Medical errors cause up to 98,000 preventable deaths annually in the US. The study aims to determine if providing education on tort law concepts would improve healthcare workers' understanding of negligence and reduce errors. The null hypotheses are that there is no significant difference between errors and lack of education, and that quantitative strategies have no impact on error rates.
Making the case for cost-effective wound managementGNEAUPP.
This document discusses cost-effective wound management and making the case for it. It begins by explaining the challenges in wound management, including increasing prevalence of wounds and difficulty collecting data on clinical efficacy, effectiveness, and costs. It then discusses common myths around cost-effectiveness, clarifying that cost-effective does not mean cheaper but provides benefits at a reasonable cost compared to alternatives. The document outlines different types of economic analyses used in healthcare, particularly cost-effectiveness analysis, and discusses understanding costs from various perspectives.
Point Value Descriptive TitlePurpose and Analytical .docxLeilaniPoolsy
Point Value Descriptive Title
Purpose and
Analytical
Technique(s)
Summary of Results
Summary of
Conclusions
Error Analysis
Professional
Presentation
2
Title is complete and
informative, and written
in a scientific tone
A general purpose and
all relevant analytical
techniques are given
using the correct
scientific terminology
All major numerical
results are given with
correct units and
significant figures - All
important descriptive
results are given with
appropriate context
Conclusions are made
based on the results, any
accepted values are
given for comparison,
and percent error values
are provided
Errors are given,
followed through the
calculations, and the
effect on the result is
explained - Errors are
used to explain
deviations from the
expected results
Abstract is typed, proof
read, and printed on an
appropriate medium
1
Title is informative and
appropriate, yet is
somewhat incomplete,
contains errors, or is
written in an unscientific
tone
Purpose or techniques
are partially incomplete
or use layman's terms
Result section is mostly
complete, but some
relevant results are
omitted, or incorrect
units or significant
figures are used
Conclusion section is
mostly complete, but
some relevant
conclusions are omitted
Errors are given, but not
followed through the
calculations, or not used
to explain results
Abstract contains several
errors, or has
handwritten edits
0
Title is absent, or neither
informative nor
appropriate
Section is absent or not
relevant to the
experiment
Section is absent, less
than half complete, or
not relevant to the
experiment
Section is absent, less
than half complete, or
not relevant to the
experiment
Section is absent or not
relevant to the
experiment
Abstract is handwritten,
contains numerous
errors, or otherwise
unacceptably presented
Rubric for a Scientific Abstract
In general, abstracts will be graded on the six criteria below (column headings), worth two points each.
The resulting points out of 12 will be converted to a gradebook score out of five.
Score = (
5
/12 ) × Points
Some rules for it:
1. Font size 12, times new roman style.
2. 600 words
About Abstracts:
An abstract is a brief, written summary of the specific idea or concepts to be presented, and a statement of their relevance to practice or research.
This is one type to write abstracts:
Research abstracts: include a brief description of the author’s original objective or hypothesis research methodology, including design, participant characteristics and procedures, major findings, and conclusions or implications for dietetics.
All words should write by yourself, no quote from any website or paper.
Please check abstract grading rubric for get higher grade. Thanks.
PRACTICE APPLICATIONS
Business of Dietetics
Hospital-Acquired Conditions: Knowing, Preventing,
and Treating .
Barriers to Health Care Access for Low Income Families.docxwrite31
Patient safety issues in healthcare can arise from errors such as misdiagnosis, poor communication between providers, and an overburdened healthcare system. The most common causes of safety lapses are preventable adverse events stemming from diagnostic errors, failures to consider patient context, and miscommunication. Implementing electronic health records and improving communication standards and leadership can help create a culture of safety to reduce errors and protect patients.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
Executive CommitteeLearning Team B Adrienne Jones, .docxgitagrimston
This document outlines guidelines for a team project on an emerging technology. It discusses forming multi-member teams to research a topic like nanotechnology or robotics. Each team must produce a formal research paper and presentation. Required elements of the research include describing the technology, its history, political/legal issues, economics, psychology/sociology, culture/media, environmental impacts, and ethics. By week 1, teams must select a topic, leader, and outline with sections assigned to members. Subsequent deliverables include individual research contributions and a final group paper and presentation assessing technical and societal issues of the chosen technology.
CANCER DATA COLLECTION6The Application of Data to Problem-SoTawnaDelatorrejs
CANCER DATA COLLECTION 6
The Application of Data to Problem-Solving PEER RESPONSES
PEER NUMBER 1: Luis Arencibia
Top of Form
Clinical data is fundamental in the medical field. It is from this data that change and efficiency are made possible. Clinical data forms the basis of clinical care given to patients and research studies and is also used by the administration for decision-making and influencing change (Deckro et al., 2021). Modernization has come up with better ways of processing and storing clinical data, popularly known as informatics. This has led to the increased utilization of computers and information technology in clinical data management. The informatics results have increased efficiency in managing patients' data (McGonigle & Mastrian, 2022). It is crucial to ensure proper data management because it is from clinical data that crucial decisions and problems are solved in healthcare.
An example of a scenario where data can be helpful in problem-solving is the case where a healthcare facility wants to determine the average number of patients they receive in a day and use that information to establish whether the staff to patient ratio is satisfactory. This data can be obtained by registering all patients who attend the facility for a certain period, for example, three months, and stored electronically. The average is then done to get the approximate number of clients in a day. Additionally, the data should capture the age of patients, significant complaints, and the departments where the patients were attended. It is vital to secure this data to avoid unauthorized access to promote patients' privacy and compliance with the HIPAA to avoid legal consequences.
The knowledge derived from the data described above is the number of patients visiting the facility and their health needs. From this, the healthcare center will be able to critically analyze and evaluate whether the facility's staffing and resources are enough to meet the patients' demands. Suppose the number of patients is higher compared to the resources. In that case, the facility will be able to tell there is a shortage and the staff is being overworked, which is likely to compromise the services given to the patients.
From the data, a nurse leader can use clinical reasoning and judgment to explain why the health facility could be performing less efficiently and not meeting its goal of providing optimum medical services to patients. Additionally, the nurse could judge that the patients are not satisfied with the services provided from the data (Zhu et al., 2019). With that information, a nurse leader can successfully convince the management that there is a need for more staffing and resources to meet the patients' needs more successfully.
In conclusion, data management is crucial in the healthcare practice. With proper informatics, nurses and other healthcare providers will function optimally, and the results will be better quality ...
· Analyze how healthcare reimbursement influences your nursing praLesleyWhitesidefv
· Analyze how healthcare reimbursement influences your nursing practice.
Health care is significantly changing with time, and one of these changes is how health care facilities and providers are compensated for offering service. One of these ways is through reimbursement. Health care reimbursement is the payment given to a health care facility or a health care provider for offering medical service to a patient (Torrey, 2020). This cost is often covered by a patient’s health insurer or a government payer. In health care reimbursements are beneficial because they discourage DNP-prepared nurses from establishing their own independent practices. This is because at their own practices they would receive less reimbursement under their own number than under that of a physician. If the reimbursement rates were equal more DNP-prepared nurses would establish their own practices and this would increase competition.
Due to healthcare reimbursement, models that emphasize cost-effective decisions by DNP-prepared nurses are developed. These decisions are offer patients with quality medical care rather than sacrificing the patient service quality. Innovations such as price transparency tools as well as patient engagement apps help the nursing practice during the implementation of healthcare reimbursement. The patient outcome as well as the low-cost care provided by health care providers has an influence on the reimbursement received. Health care reimbursement tends to motivate health care providers because they earn more when the care they provide is of high quality as well as low cost.
DNP- prepared Nurses' role helps Nurse Practitioners to prepare for the advancement they will encounter in their nursing career in health care. This enables them to be more competent and have more knowledge when offering quality health care. The main goal of the health care reimbursement system is to pay health care providers based on their performance. This means that being more advanced and competent is beneficial for a DNP in order to provide high-quality care to patients. This simply means that if they offer high-quality care, the reimbursement will reflect this and they will be paid more. And if they are not competent, then the reimbursement will be vice versa.
2- Examine how the value-based insurance design (VBID) influences clinical outcomes and cost issues.
The aim of value-based insurance design is to increase the quality of health care while decreasing the cost by using financial incentives to promote cost-efficient health care services and consumer choices. In order to remove roadblocks as well as maintain and improve a person’s health, health benefit plans can be developed. These plans tend to save money by reducing future expensive medical procedures. They do this by covering treatments such as prescribed drugs at a low cost or no cost, preventive care as well as wellness visits (Lexchin, 2020).
The healthcare industry is making a shif ...
Lecture 5_Managing People & Pharmacy Operations (PART II to III) (1).pdflaonedikgang1
This document provides an overview of managing medication use processes to reduce errors. It discusses the five stages of the medication use process: prescribing, transcribing, distribution, administration, and monitoring. For each stage, potential errors are described. Centralized and decentralized drug distribution models are compared. National patient safety goals and strategies for researching and preventing errors like failure mode and effects analysis and root cause analysis are also covered. The presentation aims to describe medication use processes and discuss ways to improve safety.
When developing a business strategy centered on the patient, organizations must adapt and implement programs that foster information sharing and collaboration while providing faster and greater access to life-changing products.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
This document discusses the efforts of Partners HealthCare, a large integrated health care system, to develop a common patient safety strategy across their network.
Key elements of their approach include appointing a central Patient Safety Officer to coordinate efforts. This officer formed an Advisory Group of local experts and a Patient Safety Leaders Group of representatives from each institution. The Leaders Group meets monthly to coordinate projects and share results.
Early milestones include implementing executive leadership rounds to discuss safety, developing accountability principles, creating a common incident reporting system, and agreeing to implement computerized physician order entry across all hospitals. This work has increased awareness of patient safety issues within the network.
NURS 438 Trends And Issues In Nursing And Health Systems.docxstirlingvwriters
This document discusses trends and issues related to medical errors in nursing and health systems. It outlines several common causes of medical errors, including communication problems, inadequate information flow, and technical errors. Communication issues between nurses and patients can lead to medication errors, while inadequate discharge instructions and a lack of information for patients post-hospitalization can also result in errors. Technical failures of medical equipment during procedures have caused patient injuries and deaths. Reducing these types of errors will help improve safety and outcomes in healthcare.
Your supervisor, Sophia, Ballot Online director of information t.docxMargaritoWhitt221
Your supervisor, Sophia, Ballot Online director of information technology, has tasked you with creating a presentation that will convince the executives that using cloud-based computing to accommodate Ballot Online future growth rather than trying to expand the current infrastructure will help the company do business faster and at lower cost while conserving IT resources.
Question:
Create a high-level proposal for a compliance program for Ballot Online that enables the organization and its employees to conduct itself in a manner that is in compliance with legal and regulatory requirements.
The proposal will be one to two pages in length and should take the form of a high-level outline or flowchart showing the different components and relationships among the components.
Include the following elements that are generally found in an effective program:
● Identification of company employees who have oversight over the program, their roles, and responsibilities
● List of high-level policies and/or procedures that may be required
● List of high-level training and education programs that may be required
● Relationships between components of the program, including (but not limited to):
○ communication channels
○ dependencies
● Identification of enforcement mechanism
● Identification of monitoring and auditing mechanisms
● How will responses to compliance issues be handled, and how will corrective action plans be developed?
● How are risk assessments handled?
Please add references
.
Your selected IEP. (Rudy)Descriptions of appropriate instructi.docxMargaritoWhitt221
Your selected IEP. (Rudy)
Descriptions of appropriate instructional and assessment accommodations for the exceptional student based on their needs as described in the IEP.
You will need to list and describe the appropriate assessment tools and accommodations.
You will also need to describe how the lesson can be modified for other learners with varying reading deficiencies.
Rudy IEP
Current Grade: 2
Present Levels of Educational Performance
• Ruby is in good health with no known physical performance issues, and she socializes well with her peers.
• Ruby performs at grade level in all subjects except reading.
• Ruby can identify all letters of the alphabet and knows the sound of most consonants and short vowels.
• Her sight vocabulary is approximately 65 to 70 words, and she reads on the primer level.
• Ruby can spell most words in a first-grade textbook, but has difficulty with words in the second-grade textbook.
Annual Goals
1. By the end of the school year, Ruby will read at a beginning second-grade level with 90% accuracy in word recognition and 80% accu- racy in word comprehension.
Person Responsible: Resource Teacher
2. By the end of the school year, Ruby will increase her sight word vocabulary to 150 words.
Person Responsible: Resource Teacher
3. By the end of the school year, Ruby will read and spell at least 75% of the second-grade spelling words.
Person Responsible: Second-Grade Teacher
Amount of Participation in General Education
• Ruby will participate in all second-grade classes and activities except for reading.
Special Education and Related Services
• Ruby will receive individualized and/or small-group instruction in reading from the Resource Teacher for 30 minutes each day.
.
More Related Content
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in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
INTEGRATING MACHINE LEARNING IN CLINICAL DECISION SUPPORT SYSTEMShiij
This review article examines the role of machine learning (ML) in enhancing Clinical Decision Support
Systems (CDSSs) within the modern healthcare landscape. Focusing on the integration of various ML
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potential in advancing patient care. A rapid review methodology was utilized, involving a survey of recent
articles from PubMed and Google Scholar on ML applications in healthcare. Key findings include the
demonstration of ML's predictive power in patient outcomes, its ability to augment clinician knowledge,
and the effectiveness of ensemble algorithmic approaches. The review highlights specific applications of
diverse ML models, including moment kernel machines in predicting surgical outcomes, k-means clustering
in simplifying disease phenotypes, and extreme gradient boosting in estimating injury risk. Emphasizing
the potential of ML to tackle current healthcare challenges, the article highlights the critical role of ML in
evolving CDSSs for improved clinical decision-making and patient care. This comprehensive review also
addresses the challenges and limitations of integrating ML into healthcare systems, advocating for a
collaborative approach to refine these systems for safety, efficacy, and equity.
Goal 1 improve the accuracy of patient identification.npsssuser47f0be
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Diabetes Management Policy Proposal
Miatta Teasley
Capella University
NHS-FPX6004 Health Care Law and Policy
Professor Georgena Wiley
May 19, 2022
Click to edit Master title style
Click to edit Master title style
Hello and welcome to today's presentation on drug error regulatory policy proposals. This presentation is intended to provide you, your stakeholders, with all pertinent information regarding the need for an institutional policy to reduce medication errors in medical centers. We will also go over the scope of the recommendations, strategies for addressing medication errors, and stakeholder involvement in putting these strategies into action.
Policy Proposal
Diabetes Management
2
Click to edit Master title style
Click to edit Master title style
This proposal revolves around creating and implementing strategies that will help Med’s caregivers be able to improve on patient care regarding diabetes.
Presentation Outline
Policy on Managing Medication Errors
Need for a Policy
Scope of Policy
Strategies to Resolve Mediation Errors
Role of the Hospital Staff
Positive impact on Working Conditions
Issues in the Application of Strategies
Alterative Perspectives on Mitigating Medication Errors
Stakeholder Participation
3
Click to edit Master title style
Click to edit Master title style
The presentation highlights key functions in any policy implementation process. The steps this presentation takes appear in the order as indicated here. We will start y looking at
Policy on Managing Medication Errors then
Need for a Policy followed by
Strategies to Resolve Mediation Errors. Then the
Role of the Hospital Staff and the
Positive impact on Working Conditions. Also, we will look at
Issues in the Application of Strategies and the
Alterative Perspectives on Mitigating Medication Errors and finally,
Stakeholder Participation
Policy on Managing Medication Errors
4
Health practitioners should create and advance engaging policies
Many Healthcare departments require modernization
Healthcare policies should be adjusted to meet defined benchmarks
Key stakeholders are vital for successful implementation of proposed policies
Click to edit Master title style
Click to edit Master title style
When advocating for organizational regulation changes about federal, state, or local health care guidelines or rules and regulations, healthcare practitioners should be able to create and advance an engaging and logical policy and guideline parameters that will provide a segment, a group, or an entire institution to correct and shed light on issues of accomplishment and execute developments in the quality and safety of medical management.
Despite being recognized as one of the greatest health insurance carriers for people over 65, several departments need to be modernized. The most pr.
Problem And Description Of Terms For DisseratationJenniferlaw1
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Making the case for cost-effective wound managementGNEAUPP.
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Point Value Descriptive TitlePurpose and Analytical .docxLeilaniPoolsy
Point Value Descriptive Title
Purpose and
Analytical
Technique(s)
Summary of Results
Summary of
Conclusions
Error Analysis
Professional
Presentation
2
Title is complete and
informative, and written
in a scientific tone
A general purpose and
all relevant analytical
techniques are given
using the correct
scientific terminology
All major numerical
results are given with
correct units and
significant figures - All
important descriptive
results are given with
appropriate context
Conclusions are made
based on the results, any
accepted values are
given for comparison,
and percent error values
are provided
Errors are given,
followed through the
calculations, and the
effect on the result is
explained - Errors are
used to explain
deviations from the
expected results
Abstract is typed, proof
read, and printed on an
appropriate medium
1
Title is informative and
appropriate, yet is
somewhat incomplete,
contains errors, or is
written in an unscientific
tone
Purpose or techniques
are partially incomplete
or use layman's terms
Result section is mostly
complete, but some
relevant results are
omitted, or incorrect
units or significant
figures are used
Conclusion section is
mostly complete, but
some relevant
conclusions are omitted
Errors are given, but not
followed through the
calculations, or not used
to explain results
Abstract contains several
errors, or has
handwritten edits
0
Title is absent, or neither
informative nor
appropriate
Section is absent or not
relevant to the
experiment
Section is absent, less
than half complete, or
not relevant to the
experiment
Section is absent, less
than half complete, or
not relevant to the
experiment
Section is absent or not
relevant to the
experiment
Abstract is handwritten,
contains numerous
errors, or otherwise
unacceptably presented
Rubric for a Scientific Abstract
In general, abstracts will be graded on the six criteria below (column headings), worth two points each.
The resulting points out of 12 will be converted to a gradebook score out of five.
Score = (
5
/12 ) × Points
Some rules for it:
1. Font size 12, times new roman style.
2. 600 words
About Abstracts:
An abstract is a brief, written summary of the specific idea or concepts to be presented, and a statement of their relevance to practice or research.
This is one type to write abstracts:
Research abstracts: include a brief description of the author’s original objective or hypothesis research methodology, including design, participant characteristics and procedures, major findings, and conclusions or implications for dietetics.
All words should write by yourself, no quote from any website or paper.
Please check abstract grading rubric for get higher grade. Thanks.
PRACTICE APPLICATIONS
Business of Dietetics
Hospital-Acquired Conditions: Knowing, Preventing,
and Treating .
Barriers to Health Care Access for Low Income Families.docxwrite31
Patient safety issues in healthcare can arise from errors such as misdiagnosis, poor communication between providers, and an overburdened healthcare system. The most common causes of safety lapses are preventable adverse events stemming from diagnostic errors, failures to consider patient context, and miscommunication. Implementing electronic health records and improving communication standards and leadership can help create a culture of safety to reduce errors and protect patients.
Defensive medicine effect on costs, quality, and access to healthcareAlexander Decker
This document discusses the practice of defensive medicine and its effects. Defensive medicine occurs when doctors order unnecessary tests or procedures in an attempt to reduce malpractice liability. The document finds that defensive medicine increases healthcare costs and can lower quality by leading doctors to avoid high-risk patients or procedures. It also discusses how defensive medicine practices like unnecessary referrals and extra diagnostic tests can limit access to care. The document examines factors that contribute to defensive medicine and its negative impacts on healthcare systems.
Executive CommitteeLearning Team B Adrienne Jones, .docxgitagrimston
This document outlines guidelines for a team project on an emerging technology. It discusses forming multi-member teams to research a topic like nanotechnology or robotics. Each team must produce a formal research paper and presentation. Required elements of the research include describing the technology, its history, political/legal issues, economics, psychology/sociology, culture/media, environmental impacts, and ethics. By week 1, teams must select a topic, leader, and outline with sections assigned to members. Subsequent deliverables include individual research contributions and a final group paper and presentation assessing technical and societal issues of the chosen technology.
CANCER DATA COLLECTION6The Application of Data to Problem-SoTawnaDelatorrejs
CANCER DATA COLLECTION 6
The Application of Data to Problem-Solving PEER RESPONSES
PEER NUMBER 1: Luis Arencibia
Top of Form
Clinical data is fundamental in the medical field. It is from this data that change and efficiency are made possible. Clinical data forms the basis of clinical care given to patients and research studies and is also used by the administration for decision-making and influencing change (Deckro et al., 2021). Modernization has come up with better ways of processing and storing clinical data, popularly known as informatics. This has led to the increased utilization of computers and information technology in clinical data management. The informatics results have increased efficiency in managing patients' data (McGonigle & Mastrian, 2022). It is crucial to ensure proper data management because it is from clinical data that crucial decisions and problems are solved in healthcare.
An example of a scenario where data can be helpful in problem-solving is the case where a healthcare facility wants to determine the average number of patients they receive in a day and use that information to establish whether the staff to patient ratio is satisfactory. This data can be obtained by registering all patients who attend the facility for a certain period, for example, three months, and stored electronically. The average is then done to get the approximate number of clients in a day. Additionally, the data should capture the age of patients, significant complaints, and the departments where the patients were attended. It is vital to secure this data to avoid unauthorized access to promote patients' privacy and compliance with the HIPAA to avoid legal consequences.
The knowledge derived from the data described above is the number of patients visiting the facility and their health needs. From this, the healthcare center will be able to critically analyze and evaluate whether the facility's staffing and resources are enough to meet the patients' demands. Suppose the number of patients is higher compared to the resources. In that case, the facility will be able to tell there is a shortage and the staff is being overworked, which is likely to compromise the services given to the patients.
From the data, a nurse leader can use clinical reasoning and judgment to explain why the health facility could be performing less efficiently and not meeting its goal of providing optimum medical services to patients. Additionally, the nurse could judge that the patients are not satisfied with the services provided from the data (Zhu et al., 2019). With that information, a nurse leader can successfully convince the management that there is a need for more staffing and resources to meet the patients' needs more successfully.
In conclusion, data management is crucial in the healthcare practice. With proper informatics, nurses and other healthcare providers will function optimally, and the results will be better quality ...
· Analyze how healthcare reimbursement influences your nursing praLesleyWhitesidefv
· Analyze how healthcare reimbursement influences your nursing practice.
Health care is significantly changing with time, and one of these changes is how health care facilities and providers are compensated for offering service. One of these ways is through reimbursement. Health care reimbursement is the payment given to a health care facility or a health care provider for offering medical service to a patient (Torrey, 2020). This cost is often covered by a patient’s health insurer or a government payer. In health care reimbursements are beneficial because they discourage DNP-prepared nurses from establishing their own independent practices. This is because at their own practices they would receive less reimbursement under their own number than under that of a physician. If the reimbursement rates were equal more DNP-prepared nurses would establish their own practices and this would increase competition.
Due to healthcare reimbursement, models that emphasize cost-effective decisions by DNP-prepared nurses are developed. These decisions are offer patients with quality medical care rather than sacrificing the patient service quality. Innovations such as price transparency tools as well as patient engagement apps help the nursing practice during the implementation of healthcare reimbursement. The patient outcome as well as the low-cost care provided by health care providers has an influence on the reimbursement received. Health care reimbursement tends to motivate health care providers because they earn more when the care they provide is of high quality as well as low cost.
DNP- prepared Nurses' role helps Nurse Practitioners to prepare for the advancement they will encounter in their nursing career in health care. This enables them to be more competent and have more knowledge when offering quality health care. The main goal of the health care reimbursement system is to pay health care providers based on their performance. This means that being more advanced and competent is beneficial for a DNP in order to provide high-quality care to patients. This simply means that if they offer high-quality care, the reimbursement will reflect this and they will be paid more. And if they are not competent, then the reimbursement will be vice versa.
2- Examine how the value-based insurance design (VBID) influences clinical outcomes and cost issues.
The aim of value-based insurance design is to increase the quality of health care while decreasing the cost by using financial incentives to promote cost-efficient health care services and consumer choices. In order to remove roadblocks as well as maintain and improve a person’s health, health benefit plans can be developed. These plans tend to save money by reducing future expensive medical procedures. They do this by covering treatments such as prescribed drugs at a low cost or no cost, preventive care as well as wellness visits (Lexchin, 2020).
The healthcare industry is making a shif ...
Lecture 5_Managing People & Pharmacy Operations (PART II to III) (1).pdflaonedikgang1
This document provides an overview of managing medication use processes to reduce errors. It discusses the five stages of the medication use process: prescribing, transcribing, distribution, administration, and monitoring. For each stage, potential errors are described. Centralized and decentralized drug distribution models are compared. National patient safety goals and strategies for researching and preventing errors like failure mode and effects analysis and root cause analysis are also covered. The presentation aims to describe medication use processes and discuss ways to improve safety.
When developing a business strategy centered on the patient, organizations must adapt and implement programs that foster information sharing and collaboration while providing faster and greater access to life-changing products.
1) The study reviewed 122 malpractice claims from 4 insurers involving missed or delayed diagnoses in the emergency department.
2) 79 claims (65%) involved missed ED diagnoses that harmed patients, with 48% resulting in serious harm and 39% in death.
3) The leading causes of missed diagnoses were failures to order appropriate diagnostic tests or perform adequate exams, incorrect test interpretations, and failures to order appropriate consultations. The most common contributing factors were cognitive errors, patient factors, lack of supervision, and excessive workload.
This document discusses the efforts of Partners HealthCare, a large integrated health care system, to develop a common patient safety strategy across their network.
Key elements of their approach include appointing a central Patient Safety Officer to coordinate efforts. This officer formed an Advisory Group of local experts and a Patient Safety Leaders Group of representatives from each institution. The Leaders Group meets monthly to coordinate projects and share results.
Early milestones include implementing executive leadership rounds to discuss safety, developing accountability principles, creating a common incident reporting system, and agreeing to implement computerized physician order entry across all hospitals. This work has increased awareness of patient safety issues within the network.
NURS 438 Trends And Issues In Nursing And Health Systems.docxstirlingvwriters
This document discusses trends and issues related to medical errors in nursing and health systems. It outlines several common causes of medical errors, including communication problems, inadequate information flow, and technical errors. Communication issues between nurses and patients can lead to medication errors, while inadequate discharge instructions and a lack of information for patients post-hospitalization can also result in errors. Technical failures of medical equipment during procedures have caused patient injuries and deaths. Reducing these types of errors will help improve safety and outcomes in healthcare.
Similar to # 1Opportunities & Challenges with Patient Safety GoalsAnner (20)
Your supervisor, Sophia, Ballot Online director of information t.docxMargaritoWhitt221
Your supervisor, Sophia, Ballot Online director of information technology, has tasked you with creating a presentation that will convince the executives that using cloud-based computing to accommodate Ballot Online future growth rather than trying to expand the current infrastructure will help the company do business faster and at lower cost while conserving IT resources.
Question:
Create a high-level proposal for a compliance program for Ballot Online that enables the organization and its employees to conduct itself in a manner that is in compliance with legal and regulatory requirements.
The proposal will be one to two pages in length and should take the form of a high-level outline or flowchart showing the different components and relationships among the components.
Include the following elements that are generally found in an effective program:
● Identification of company employees who have oversight over the program, their roles, and responsibilities
● List of high-level policies and/or procedures that may be required
● List of high-level training and education programs that may be required
● Relationships between components of the program, including (but not limited to):
○ communication channels
○ dependencies
● Identification of enforcement mechanism
● Identification of monitoring and auditing mechanisms
● How will responses to compliance issues be handled, and how will corrective action plans be developed?
● How are risk assessments handled?
Please add references
.
Your selected IEP. (Rudy)Descriptions of appropriate instructi.docxMargaritoWhitt221
Your selected IEP. (Rudy)
Descriptions of appropriate instructional and assessment accommodations for the exceptional student based on their needs as described in the IEP.
You will need to list and describe the appropriate assessment tools and accommodations.
You will also need to describe how the lesson can be modified for other learners with varying reading deficiencies.
Rudy IEP
Current Grade: 2
Present Levels of Educational Performance
• Ruby is in good health with no known physical performance issues, and she socializes well with her peers.
• Ruby performs at grade level in all subjects except reading.
• Ruby can identify all letters of the alphabet and knows the sound of most consonants and short vowels.
• Her sight vocabulary is approximately 65 to 70 words, and she reads on the primer level.
• Ruby can spell most words in a first-grade textbook, but has difficulty with words in the second-grade textbook.
Annual Goals
1. By the end of the school year, Ruby will read at a beginning second-grade level with 90% accuracy in word recognition and 80% accu- racy in word comprehension.
Person Responsible: Resource Teacher
2. By the end of the school year, Ruby will increase her sight word vocabulary to 150 words.
Person Responsible: Resource Teacher
3. By the end of the school year, Ruby will read and spell at least 75% of the second-grade spelling words.
Person Responsible: Second-Grade Teacher
Amount of Participation in General Education
• Ruby will participate in all second-grade classes and activities except for reading.
Special Education and Related Services
• Ruby will receive individualized and/or small-group instruction in reading from the Resource Teacher for 30 minutes each day.
.
Your project sponsor and customer are impressed with your project .docxMargaritoWhitt221
Your project sponsor and customer are impressed with your project schedule, but due to some factors out of their control, you’ve been told to deliver your project early, roughly 15% earlier than anticipated. Using the information from the readings, explain how you would go about assessing the possibility of delivering your project early. How will that affect scope, costs, and schedule?
.
Your initial post should use APA formatted in-text citations whe.docxMargaritoWhitt221
Your initial post for class discussions should include APA formatted in-text citations when paraphrasing or directly quoting outside sources like the textbook. You must also include an APA formatted reference list at the end of your post. Posts should be at least 150 words long.
Your life is somewhere in a databaseContains unread posts.docxMargaritoWhitt221
Your life is somewhere in a database
Contains unread posts
(Clipart from MS Office)
Many TV shows depict law enforcement personnel accessing readily accessible databases that contain all types of records about individuals –records about everything from address to telephone records to finances, insurance, and criminal history. The information you share with your bank, doctor, insurance agent, the TSA, ancestry kit companies, and on social media can make your life an open book. Here are some questions to address as you reflect on this:
1. Are you comfortable with giving away some of your privacy for increased security? Why or why not? How far would you let the government go in examining people's private lives?
2. How much access should we have to certain aspects of others' private lives? For example, should States share criminal databases? But should a database of people paroled or released for crimes be made public? Why or why not?
.
Your original initial post should be between 200-300 words and 2 pee.docxMargaritoWhitt221
Your original initial post should be between 200-300 words and 2 peer responses in the range of 75-125 words each. Posts are too brief for a cover page and double-spacing. Otherwise, your posts, references and citations should be in APA format. The rubrics with Biblical Integration determines your grade. It considers:
Providing a short introduction stating your position and argument
Supporting your argument (intext citing shows this)
When all is done, give a brief conclusion
a reference at the end
In this chapter, Collins begins the process of identifying and further developing from the research those unique factors and variables that differentiated the good and great companies. One of the most significant differences, he asserts, is the quality and nature of leadership in the firm. Collins initially told the research team to downplay the role of top executives in the good-to-great process. It became obvious that there was something different that these leaders did. Collins went on to identify "Level 5 leadership" as a common characteristic of the great companies assessed in the study. By further studying the behaviors and attitudes of so-called Level 5 leaders, Collins found that many of those classified in this group displayed an unusual mix of intense determination and profound humility. Characteristics used to describe these leaders included words like quiet, humble, modest, gracious, and understated. Yet there was also the stoic resolve and an unwavering determination evident. They were low-key executives, rarely appearing in the media, who demonstrated a relentless drive for results. These leaders often had a long-term personal sense of investment in the company and its success, often cultivated through a career-spanning climb up the company’s ranks. The personal ego and individual financial gain were not as important as the long-term benefit of the team and the company. As such, Collins warned of the liability involved in employing a bigger-than-life charismatic leader —personalities often brought in from outside the company or organization by a board seeking a high profile figure. The data suggested that a celebrity CEO brought in to turn around a flailing firm was usually not conducive to fostering the transition from
Good to Great
(Collins, 2001).
Why is this important?
Collins was asked and did not want to use "servant leader" for the Level 5 leader (Lichtenwalner, 2012). The team chose the term, “Level 5 Leadership” over Servant Leadership, in part, for fear readers would misinterpret the concept as “servitude” or “weakness.” In his mind, this position looked like something else. And so a new leadership phrase was born. What is interesting is that many but not all of the leaders profiled had a faith background. Lichtenwalner, (2012) in his research suggests that Servant Leadership is a key aspect of Level 5 Leadership. But perhaps it is not the technique but the heart and faith of the leader that had such a signifi.
Your assignment is to research and report about an archaeological fi.docxMargaritoWhitt221
Your assignment is to research and report about an archaeological find of the last fifteen years.
When you begin the research phase of your project, you will be happily surprised to find just how many active sites are producing new insights into ancient cultures every single day. Some recent examples include excavations in Scotland, England, Egypt, Jerusalem, Rome, and China. Find one that interests you.
Please message me for full assignment information as I am not able to post it.
.
Your assignment for Physical Science I is to write a paper on.docxMargaritoWhitt221
Your assignment for Physical Science I is to write a paper on:
Clean Energy as well as an alternatives and the Environments: Solar, Geological (Geothermal!), and Wind Energy for the Future. Also, Hydro Power Plants, Dams, and the Water Table and Ecology Issues.
1200 words.
.
Your charge is to develop a program using comparative research, anal.docxMargaritoWhitt221
Your charge is to develop a program using comparative research, analyzing the relationship of workplace behavior and employee motivation. Create a diversity mentoring program (DMP) for an organization of your choosing. You may select a current or former employer, church, hobby team, etc.Within your plan, include the following items listed below:
name of organization;
introduction of DMP;
need of such program;
benefits of the program;
potential challenges (may include potential problems that may incur without such program);
justification of the important aspects of employee behavior and the relationship to employee motivation;
one inclusion of a motivation theory;
details of the equity of social justice and the power to make positive change; and
explanation of the plan to implement the program with recommendations with inclusion of the expected outcomes.
Two pages
.
Young consumers’ insights on brand equity Effects of bra.docxMargaritoWhitt221
Young consumers’ insights on brand equity
Effects of brand loyalty, brand awareness, and brand image
1
CONTENTS
INTRODUCTION
LITERATURE REVIEW
METHODOLOGY
2
- Data set development
- Customer expectation
--Brand recognition
--The quality of the brand is guaranteed
- Advantage of Brand effect
-- Increase market share
--Increase of competitive advantage
Research Background
- Data set development
- Customer expectation
--Brand recognition
--The quality of the brand is guaranteed
- Advantage of Brand effect
-- Increase market share
--Increase of competitive advantage
Research Background
3
Research problem
-Limited research
-Different research perspectives
-The impact factor of brand equity
Research objectives
The purpose of this study is to measure the relationship between brand loyalty, brand awareness and brand image and brand equity of young consumers.
Aaker (1991) Model theory was incorporated into the relevant research system
Identify the relationship between brand equity and brand loyalty, brand awareness and brand image
The research scope of brand effect has been expanded
Provide guidance for enterprises to design effective strategies
Significant of study
Contribution
Scope of study
Master students are the main research objects, and the research scope is to investigate Chinese master students.
THEORETICAL FRAMEWORK
The conclusion of this paper is based on the principle of Aaker (1991) model.
It can be said that customers' attitude towards brands has an important impact on brand assets (Choi, Parsa, Sigala, & Putrevu, 2009).
Thwaites et al. (2012) found that when consumers' perception of brand cognition is positive, their purchase intention of brand will also be positive.
LITERATURE REVIEW
Brand loyalty
The study found that the creative consumption behavior of customers has a positive effect on the cultivation of brand loyalty, and the brand equity associated with high brand loyalty of consumers is higher than that of other brands (Atilgan, Aksoy, & Akinci, 2005).
Brand awareness
According to the research, when customers‘ brand awareness is enhanced and they have a certain understanding of brand awareness, the brand equity will also be further enhanced,It can be said that there is a significant influence relationship between brand awareness and brand equity (Pouromid & Iranzadeh, 2012).
LITERATURE REVIEW
Brand image
Most consumers will choose products with good brand image and feel that such products are of relatively high quality (Rubio, Oubina, & Villasenor, 2014).
Relevant studies, such as Faircloth et al. (2001), Rubio et al. (2014), and Vahie and Paswan (2006), have confirmed the positive influence of brand image on brand equity.
Brand equity is the added value of a product or a service, which mainly reflects the customer's evaluation and use of the brand, and also reflects the competitive advantage, price advantage and profitability brought by the brand to the enterp.
You will examine a scenario that includes an inter-group conflict. I.docxMargaritoWhitt221
You will examine a scenario that includes an inter-group conflict. In this scenario, you are recognized as an authority in cross-cultural psychology and asked to serve as a consultant to help resolve the conflict. You will be asked to write up your recommendations in a 5–6page paper not including your title and reference page.
Reference
Darley, J.M. & Latané, B. (1968). Bystander interview in emergencies: Diffusion of responsibility. Journal of Personality and Social Psychology, 8(4), 377-383.
To Prepare:
Review the following:
Scenario: Culture, Psychology, and Community
Imagine an international organization has approached you to help resolve an inter-group conflict. You are an authority in cross-cultural psychology and have been asked to serve as a consultant based on a recent violent conflict involving a refugee community in your town and a local community organization. In the days, weeks, and months leading up to the violent conflict, there were incidents of discrimination and debates regarding the different views and practices people held about work, family, schools, and religious practice. Among the controversies has been the role of women’s participation in political, educational, and community groups.
(6 pages excluding title page and reference page)
:
Part 1: Developing an Understanding
(2 pages)
Based on the scenario, explain how you can help integrate the two diverse communities so that there is increased understanding and appreciation of each group by the other group. (
Note
: Make sure to include in your explanation the different views and practices of cultural groups as well as the role of women.)
Based on your knowledge of culture and psychology, provide three possible suggestions/solutions that will help the community as a whole. In your suggestions make sure to include an explanation regarding group think and individualism vs. collectivism.
Part 2: Socio-Emotional, Cognitive, and Behavioral Aspects
(2 pages)
Based on your explanations in Part 1, how do your suggestions/solutions impact the socio-emotional, cognitive, and behavior aspects of the scenario and why?
Part 3: Gender, Cultural Values and Dimensions, and Group Dynamics
(2 pages)
Explain the impact of gender, cultural values and dimensions, and group dynamics in the scenario.
Further explain any implications that may arise from when working between and within groups.
Support your Assignment by citing all resources in APA
Learning Resources
Required Readings
Ahmed, R., & Gielen, U. (2017). Women in Egypt. In C. M. Brown, U. P. Gielen, J. L. Gibbons, & J. Kuriansky (Eds.), Women's evolving lives: Global and psychosocial perspectives (pp. 91–116). New York, NY: Springer.
Credit Line: Women's Evolving Lives: Global and Psychosocial Perspectives, by Brown, C.; Gielen, U.; Gibbons, J.; Kuriansky, J. (eds). Copyright 2017 by Springer International Publishing. Reprinted by permission of Springer International Publishing via the Copyright Clearance .
You will perform a history of a head, ear, or eye problem that y.docxMargaritoWhitt221
The student will conduct a history and assessment of a head, ear, or eye problem provided by their instructor or from their own experience. They will document their findings, identify any actual or potential risks, and submit a Word document with this information to an assignment drop box. The assignment is due based on the course calendar dates.
You need to enable JavaScript to run this app. .docxMargaritoWhitt221
You need to enable JavaScript to run this app.
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Management
Richard L. Daft
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Cover Pagecover
Title Pagei
HEOA-1HEOA-1
Copyright Pageii
Dedication Pageiii
About the Authorv
Brief Contentsvii
Contentsvix
Prefacexv
Chapter 1: Leading Edge Management2
Chapter 2: The Evolution of Management Thinking38
Chapter 3: The Environment and Corporate Culture74
Chapter 4: Managing in a Global Environment110
Chapter 5: Managing Ethics and Social Responsibility144
Chapter 6: Managing Start-Ups and New Ventures180
Chapter 7: Planning and Goal Setting216
Chapter 8: Strategy Formulation and Execution248
Chapter 9: Managerial Decision Making284
Chapter 10: Designing Organization Structure324
Chapter 11: Managing Innovation and Change370
Chapter 12: Managing Human Talent406
Chapter 13: Managing Diversity and Inclusion446
Chapter 14: Understanding Individual Behavior484
Chapter 15: Leadership528
Chapter 16: Motivating Employees570
Chapter 17: Managing Communication608
Chapter 18: Leading Teams648
Chapter 19: Managing Quality and Performance688
Appendix: Operations Management and E-Commerce721
Name Index741
Company Index756
Subject Index761
Open/Close Margin
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Chapter 8: Strategy Formulation and Execution | Page 248
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Quality tools, methods paper
In the assigned textbook (chapter 15 p. 269), the authors present a table describing how the used the model for improvement, PDSA, and lean six sigma as a tool to develop their organization’s plan for improvement.
Studying the situation in your organization, present a suggested improvement plan (present a table similar to the one in p.269 + two pages explanation) utilizing one or more of the models discussed in the class (see chapter 2).
Grading rubric:
1. Quality of the table: at last, one of the quality models/tools should be applied correctly
2. Adequate explanation is given to support and explain the table
3. General organization of the assignment. Correct grammar and spelling are used
Note:
Suggested improvement plan is:
Decreased number of urinary catheter infections.
.
You will act as a critic for some of the main subjects covered i.docxMargaritoWhitt221
You will act as a critic for some of the main subjects covered in the humanities. You will conduct a series of short, evaluative critiques of film, philosophy, literature, music, and myth. You will respond to five different prompts, and each response should include an analysis of the topics using terminology unique to that subject area and should include an evaluation as to why the topic stands the test of time. The five prompts are as follows:
1:
Choose a film and offer an analysis of why it is an important film, and discuss it in terms of film as art. Your response should be more than a summary of the film.
2:
Imagine you had known Plato and Aristotle and you had a conversation about how we
fall in love
. Provide an overview of how Plato would explain falling in love, and then provide an overview of how Aristotle might explain falling in love.
3:
Compare and contrast the two poems below:
LOVE’S INCONSISTENCY
I find no peace, and all my war is done;
I fear and hope, I burn and freeze likewise
I fly above the wind, yet cannot rise;
And nought I have, yet all the world I seize on;
That looseth, nor locketh, holdeth me in prison, And holds me not, yet can I ’scape no wise;
Nor lets me live, nor die, at my devise,
And yet of death it giveth none occasion.
Without eyes I see, and without tongue I plain;
I wish to perish, yet I ask for health;
I love another, and yet I hate myself;
I feed in sorrow, and laugh in all my pain;
Lo, thus displeaseth me both death and life,
And my delight is causer of my grief.
Petrarch
After great pain a formal feeling comes—
The nerves sit ceremonious like tombs;
The stiff Heart questions—was it He that bore?
And yesterday—or centuries before?
The feet mechanical go round
A wooden way
Of ground or air or ought
Regardless grown,
A quartz contentment like a stone.
This is the hour of lead
Remembered if outlived
As freezing persons recollect
The snow—
First chill, then stupor, then
The letting go
Emily Dickinson
4:
Compare and contrast these two pieces of music: see files attached below
Beethoven’s Violin Romance No. 2
Scott Joplin’s Maple Leaf Rag
5:
Explain in classical terms why a modern character is a hero. Choose from either Luke Skywalker, Indiana Jones, Bilbo Baggins, Harry Potter, Katniss Everdeen, or Ender Wiggins.
.
You will research and prepare a presentation about image. Your rese.docxMargaritoWhitt221
You will research and prepare a presentation about image. Your research / presentation should provide the following information / answers:
What is raster image? List two (2) common types of raster image.
What is a vector image? List two (2) common types of vector image.
Create a table listing pros and cons comparing raster vs. vector images. You should present at list three (3) pros and three (3) cons for each type of image.
Show one (1) good and (1) bad example of raster image. Explain why it is a good and bad example.
Show two (2) examples of vector images.
What is the difference between ppi and dpi?
Which are the common resolution used for: website, plotter, banner and social media. Why do we use different resolution for each type of media?
How you identify the real size of an image using resolution and pixels?
.
You will be asked to respond to five different scenarios. Answer eac.docxMargaritoWhitt221
You will be asked to respond to five different scenarios. Answer each scenario (about 1 page per scenario). You will need to:
Decide what action the responding officer should take and provide an explanation/justification for your response.
In your explanation, explain the role that discretion played in your decision. Choose at least five factors from the list below to include in your explanation.
When considering your response for each scenario, remember that because of the nature of law enforcement work, police officers have always maintained a certain amount of discretion. Due to the amount of interaction that officers have with members of the public, this discretion must be fair, equal, impartial, and legal. As such, the use of discretion by officers is both a foundation of police work and a component of community policing.
Note
: You may make any and all assumptions necessary to answer these scenarios as long as they do not conflict with the details provided.
FACTORS (CHOOSE AT LEAST 5 FOR EACH SCENARIO):
Environmental factors
Nature of the community.
Socio-demographic characteristics.
Level and type of crime in the community.
Police/Community relations.
Organizational factors
Department Rules and Regulations.
Policies and Procedures.
Department bureaucracy.
Officer experience.
Dimensions of policing: philosophical; strategic; tactical; organizational.
Situational factors
Seriousness of crime.
Weapon involvement.
Victim – Desire to prosecute.
Group/gang crime.
Suspect’s demeanor.
Age/gender/race of involved parties.
Suspect’s criminal record.
Ethics
Moral values.
Cultural/Societal norms.
Accountability.
Friends/Family/Coworkers.
Experience/Upbringing.
Legal
Laws.
Past practice.
Evidence.
Victim signatures.
Landmark Supreme Court cases.
Scenario 1:
Officer Merced responds to a call of a Theft in Progress. Upon arrival, he finds that an 18-year-old female has stolen baby formula and diapers by exiting the store without paying. He speaks with her and finds that she has a newborn baby, does not have any source of income, and needed the formula and diapers for the baby. As such, theft is still a crime. What should Officer Merced do?
Do you arrest the woman or not? What factors influenced your decision?
Provide an explanation/justification for your chosen response including the role that discretion played in your decision.
Be sure to consider at least five of the provided factors in your explanation.
Use evidence and details from the scenario as well as supporting information and examples from the text in your response.
Scenario 2:
Dane is in an electronics store where he and a couple of friends are searching for a potential gift to give to a friend. They are happy to find a video game that is on sale but decide to continue looking around the store. They decide to go grab a bite to eat before making a final decision on what to get for their friend. As they are walking .
You might find that using analysis tools to analyze internal .docxMargaritoWhitt221
You might find that using analysis tools to analyze internal
and external environments is an effective way of analyzing the
chosen capstone organization. If you need to learn more
about these types of analysis tools, check out the resources
below.
Internal Analysis Tools
• tutor2u. (2016). PESTLE (PEST) analysis
explained [Video]. YouTube. https://www.youtube.com/
watch?v=sP2sDw5waEU
• SmartDraw. (n.d.). SWOT analysis. https://
www.smartdraw.com/swot-analysis/
• SWOT Framework.
External Analysis Tools
• Applying VRIO and PESTLE.
• PESTLE Analysis. (n.d.). What is PESTLE analysis? A
tool for business analysis. http://pestleanalysis.com/what-
is-pestle-analysis/
• Study.com. (n.d.). What is PESTLE analysis? Definition
and examples. https://study.com/academy/lesson/what-
is-pestle-analysis-definition-examples.html
• Management & Finance1 TU Delft. (2016). The five
competitive forces that shape strategy [Video]. YouTube.
https://www.youtube.com/watch?v=mYF2_FBCvXw
Use these resources as you see appropriate:
• Research Guide – MBA
https://www.youtube.com/watch?v=sP2sDw5waEU
https://www.youtube.com/watch?v=sP2sDw5waEU
https://www.youtube.com/watch?v=sP2sDw5waEU
https://www.smartdraw.com/swot-analysis/
http://media.capella.edu/CourseMedia/MBA5006/GuidedPath/SWOTFramework/wrapper.asp
http://media.capella.edu/CourseMedia/MBA5006/GuidedPath/ApplyVRIOandPESTLE/wrapper.asp
http://pestleanalysis.com/what-is-pestle-analysis/
http://pestleanalysis.com/what-is-pestle-analysis/
https://study.com/academy/lesson/what-is-pestle-analysis-definition-examples.html
https://study.com/academy/lesson/what-is-pestle-analysis-definition-examples.html
https://www.youtube.com/watch?v=mYF2_FBCvXw
https://www.youtube.com/watch?v=mYF2_FBCvXw
https://www.youtube.com/watch?v=mYF2_FBCvXw
https://capellauniversity.libguides.com/MBA
• This research guide was custom created to help
MBA learners. If you are feeling a bit lost on where
to start, this would be a good starting point.
• James, N. (2007). Writing at work: How to write clearly,
effectively and professionally. Crows Nest, Australia:
Allen & Unwin.
• Use this as a general writing handbook. For
example, there are chapters on tone, grammar,
punctuation, style, et cetera.
https://capella.skillport.com/skillportfe/custom/login/saml/login.action?courseaction=launch&assetid=_ss_book:25059
https://capella.skillport.com/skillportfe/custom/login/saml/login.action?courseaction=launch&assetid=_ss_book:25059
1
MBA Capstone Project Description
MBA Capstone Project Description
Throughout your MBA program, you have worked to develop as a business professional and
prepare to meet future challenges as a business leader. Your program culminates in the
capstone project, which forms the primary focus of MBA-FPX5910, the final course you will take
in the program. The capstone project is intended to provide you the opportunity to demonstrate
your MBA program outcomes by:
• Planning and executing .
You will conduct a professional interview with a staff nurse and a s.docxMargaritoWhitt221
You will conduct a professional interview with a staff nurse and a staff nurse leader to discover their intra/inter-professional communications styles. It will be important to incorporate learning objectives regarding therapeutic communication styles including their method of caring, assertive, and responsible communication in your discussion/analysis of the interview.
.
You have chosen the topic of Computer Forensics for your researc.docxMargaritoWhitt221
This document provides instructions for a research project on computer forensics. The research project must include an abstract, introduction, section on computer forensics, and conclusion. It must be 500 words with in-text citations and 4 references.
1.Describe some of the landmark Supreme Court decisions that h.docxMargaritoWhitt221
1.
Describe some of the landmark Supreme Court decisions that have influenced present-day juvenile justice procedures.
2.
How are children processed by the juvenile justice system from arrest to reentry into society?
3.
Discuss the key issues of the preadjudicatory stage of juvenile justice including detention, intake, diversion, pretrial release, plea bargaining and waiver.
Textbook for the class
Siegel, Welsh, and Senna.
(2014).
Juvenile Delinquency: Theory, Practice, and Law
(12). Cengage Learning. [ISBN-978-1-285-45840-3]
Format:
should be thoroughly researched and reported. References and sources should be listed in MLA or APA format. The average length paper is two to three pages. You may interview individuals currently employed or retired from the criminal justice system and use them as a reference. All writing assignments must be original work for this course. Do not submit a paper used in another course. Do not cut and paste paragraphs of information into your paper. All source material should be paraphrased in your own words. Short quotations are allowed.
this paper wil be scanned through turntin
.
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
🔥🔥🔥🔥🔥🔥🔥🔥🔥
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
CapTechTalks Webinar Slides June 2024 Donovan Wright.pptxCapitolTechU
Slides from a Capitol Technology University webinar held June 20, 2024. The webinar featured Dr. Donovan Wright, presenting on the Department of Defense Digital Transformation.
Creative Restart 2024: Mike Martin - Finding a way around “no”Taste
Ideas that are good for business and good for the world that we live in, are what I’m passionate about.
Some ideas take a year to make, some take 8 years. I want to share two projects that best illustrate this and why it is never good to stop at “no”.
SWOT analysis in the project Keeping the Memory @live.pptx
# 1Opportunities & Challenges with Patient Safety GoalsAnner
1. # 1
Opportunities & Challenges with Patient Safety Goals
Annerys Velazco
St. Thomas University
NUR 415 AP 1
Dr. Rosa Rousseau
08/04/22
The Joint Commission established the National Patient Safety
Goals in 2003 as a program to promote quality and patient
safety. The NPSGs were developed to assist accredited
organizations in addressing specific patient safety concerns.
The selected 2022 NPSG for this study is Goal 3: improving the
safety of using medications (NPSG.03.04.01). In perioperative
and other procedural settings, all drugs should be labeled,
including medication containers, and other solutions on and off
the sterile field. In this case, medication containers include
syringes, medicine cups, and basins. In the clinical settings, the
unlabeled medications and other solutions are usually
unidentifiable. As a result, errors, sometimes fatal, have
occurred as a result of drugs and other solutions being removed
from their original containers and placed in unlabeled
containers (Larmené-Beld et al., 2018). This dangerous practice
is a direct violation of the basic principles of safe medication
administration, and yet, it is common practice in many
workplaces. Therefore, this NPSG goal ensures that there is
labeling of all pills, medication containers, and other solutions
in a process that is risk-reducing and is much compatible with
good medication management practices. Further, the goal
addresses a known danger point in the delivery and
administration of drugs in perioperative and other procedural
settings.
To fully achieve this goal there are various elements of
2. performance that need to be achieved. First, the healthcare
provider has to label drugs and solutions that are not
immediately provided in the perioperative and other procedural
settings. This is true even if only one medicine is utilized.
According to Bowdle et al. (2018), in the sterile field today, the
labelling errors usually involve the mixing of two liquids in
labelled containers. As such, the approach that is necessary to
prevent these errors, supported by 2022 NPSG goal 3, is
straightforward and very simple and that is; correct and full
labeling of all solution and drug containers on the sterile field
in every procedural area, every time. The second element of
performance is that labeling occurs in perioperative and other
procedural settings on and off the sterile field when any medical
solution is transferred from the original packing to another
container. The basic function of a label in this case is to
guarantee that healthcare provider and the patient can readily
identify the medicine even if it has been placed in a new
container. It is essential to note that, there may arise confusion
between medications with similar names, labels, or packaging.
This has been recognized as a major source of error among
healthcare providers who administer medication to patients.
Overall, there has been many cases of medication errors that
arise from poor labelling of drug containers which has prompted
a national focus on unlabeled medication and solution
containers by the Joint Commission and other relevant
institutions. It is evident that healthcare professionals are aware
of the risks that are linked to labeling of medication solution
containers, especially in the preoperative settings. Hence, the
recurrence of this error indicates that healthcare providers have
lost sight of the risks associated with unlabeled products, have
incorrectly believed the risk is justified and minor, or have
forgotten to apply effective prevention efforts in all procedural
areas. This brings up the aspect of normalcy bias which leads
some healthcare providers to make an assumption that an error
would never occur when drugs are poorly labeled or a solution
is changed into another container. Besides, the unlabeled
3. containers may also be considered as ‘someone else's problem,’,
a phenomenon similar to bystander indifference in which people
ignore a problem because they believe it is irrelevant to them,
unlikely to happen, something they cannot remedy, or the
responsibility of someone else to fix. Further, some providers
assume that they have developed the ideal labeling techniques
or are able to remember their medication only to discover that
the task is onerous, error-prone, or unfeasible without system
adjustments. To help identify this issue as significant, the Joint
commission came up with the 2022 National Patient Safety
Goals where they provide for proper labelling of medical
containers in the preoperative settings.
References
Bowdle, T. A., Jelacic, S., Nair, B., Togashi, K., Caine, K.,
Bussey, L., ... & Merry, A. F. (2018). Facilitated self-reported
anaesthetic medication errors before and after implementation
of a safety bundle and barcode-based safety system. British
Journal of Anaesthesia, 121(6), 1338-1345.
https://doi.org/10.1016/j.bja.2018.09.004.
Larmené-Beld, K. H., Alting, E. K., & Taxis, K. (2018). A
systematic literature review on strategies to avoid look-alike
errors of labels. European Journal of Clinical
Pharmacology, 74(8), 985-993. https://doi.org/10.1007/s00228-
018-2471-z
# 2
Jacqueline Brown
St. Thomas University
4. NUR-415: Health Care Issues
Professor Rosa Rousseau
August 3, 2022
Opportunities & Challenges with Patient Safety Goals
Essential health services must be provided in a safe
environment for patients. Preventing and mitigating injury to
patients throughout health care is a standardized practice in
nursing practice. Constant progress based on comprehensive
training and experiences encompassing unfavorable situations is
essential for quality health care delivery. Quality health care
services should be safe, effective, and oriented to the needs of
patients worldwide. Health services must also be timely,
integrated, and efficient to reap the advantages of quality health
care. Effective patient safety plans need well-defined policies, a
capable leadership team, data to guide safety improvements,
well-trained medical workers, and active patient participation.
Delivery of quality care is in line with the realization of the
2022 National Patient Safety Goals.
According to Carayon et al. (2018), it is a fundamental idea of
systems engineering and human factors to look at the whole
system rather than just focusing on a single component. The
system’s components and interactions must be improved to
achieve this aim. The entire system needs to be considered
regarding patient safety practices like preoperative checklists.
The check-in tool may favorably or adversely impact system
aspects such as team communication and workflow. Engineering
and human aspects are rooted in system design concepts,
applied through user interaction and diverse analytical
approaches in lifelong learning cycles with education and
evaluation loops.
One of the 2022 National Patient Safety Goals is to reduce or
eliminate mistakes in surgical operations. Systems engineering
and health care differ significantly in culture, which is often
overlooked or underappreciated. There is a tendency to blame
5. patient safety accidents on the shoulders of individuals in the
healthcare industry (World Health Organization, 2018). On the
other hand, human factors aim to construct systems and
procedures designed to avoid or minimize the impact of
mistakes. Systemic methods for patient safety have been called
for many times, but individual accountability for errors persists,
indicating how entrenched this thinking is in health care.
Regarding systems engineering and human aspects, the work
style, perspective, and pace might conflict with the quick
healthcare improvement initiatives.
Communication in the healthcare context is a very dynamic and
complicated process. Including new problems, participants, and
venues present another chance to improve patient safety (Ross,
2018). To provide safe patient care, good perioperative
communication is essential. It is also a crucial component of
effective team collaboration. Communication must be precise in
an environment where many obstacles and problems exist,
making the task much more difficult. Surgical checklists and
time-out procedures have contributed to a uniform, inclusive
approach to tackling communication issues in the perioperative
setting. These issues can be addressed by postoperative
debriefing sessions, which have proven successful in the virtual
educational setting.
Patient safety may be improved through systems engineering
and human factors, particularly in preventing surgical errors.
They cover a wide range of patient safety sectors and have made
significant contributions to the design and implementation of
technology and procedures in the workplace. All the healthcare
facilities must adhere to the National patient safety goals and
ensure the patients are safe within the facilities.
References
Carayon, P., Wooldridge, A., Hose, B. Z., Salwei, M., &
Benneyan, J. (2018). Challenges and opportunities for
improving patient safety through human factors and systems
6. engineering. Health Affairs, 37(11), 1862-
1869. https://doi.org/10.1377/hlthaff.2018.0723 (Links to an
external site.)
Ross, J. (2018). Effective communication improves patient
safety. Journal of PeriAnesthesia Nursing, 33(2), 223-225.
DOI: https://doi.org/10.1016/j.jopan.2018.01.003 (Links to an
external site.)
World Health Organization. (2018). Patient safety: making
health care safer (No. WHO/HIS/SDS/2018.11). World Health
Organization. https://apps.who.int/iris/handle/10665/255507 (Li
nks to an external site.)
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Empowering Culturally and Linguistically Diverse Children and
Families
Kirmani, Mubina Hassanali
YC Young Children; Nov 2007; 62, 6; ProQuest One Academic
pg. 94
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
7. Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Click on link
https://bernardvanleer.org/app/uploads/2015/12/ECIF6_Culture-
and-learning.pdf
Then visit:
The Universal and the Particular, p. 4
Developing Communication, Learning Language, p.10
Living and Learning, pp. 19–29
Click on link:
http://cdn-
media.waldenu.edu/2dett4d/Walden/EDUC/6357/CH/mm/audio_
player/index_week5.html
Then click on “Classroom Lives and Cultural Identities
Goal 1
8. Improve the accuracy of patient identification.
NPSG.01.01.01
Use at least two patient identifiers when providing care,
treatment, and services.
--Rationale for NPSG.01.01.01--
Wrong-patient errors occur in virtually all stages of diagnosis
and treatment. The intent for this goal is two-
fold: first, to reliably identify the individual as the person for
whom the service or treatment is intended;
second, to match the service or treatment to that individual.
Acceptable identifiers may be the individual’s
name, an assigned identification number, telephone number, or
other person-specific identifier.
Newborns are at higher risk of misidentification due to their
inability to speak and lack of distinguishable
features. In addition to well-known misidentification errors
such as wrong patient/wrong procedure,
misidentification has also resulted in feeding a mother’s
expressed breastmilk to the wrong newborn, which
poses a risk of passing bodily fluids and potential pathogens to
the newborn. A reliable identification system
among all providers is necessary to prevent errors.
Element(s) of Performance for NPSG.01.01.01
1. Use at least two patient identifiers when administering
medications, blood, or blood components; when
collecting blood samples and other specimens for clinical
testing; and when providing treatments or
procedures. The patient's room number or physical location is
not used as an identifier.
10. Report critical results of tests and diagnostic procedures on a
timely basis.
--Rationale for NPSG.02.03.01--
Critical results of tests and diagnostic procedures fall
significantly outside the normal range and may indicate
a life-threatening situation. The objective is to provide the
responsible licensed caregiver these results within
an established time frame so that the patient can be promptly
treated.
Element(s) of Performance for NPSG.02.03.01
1. Develop written procedures for managing the critical results
of tests and diagnostic procedures that
address the following:
- The definition of critical results of tests and diagnostic
procedures
- By whom and to whom critical results of tests and diagnostic
procedures are reported
- The acceptable length of time between the availability and
reporting of critical results of tests and
diagnostic procedures
2. Implement the procedures for managing the critical results of
tests and diagnostic procedures.
3. Evaluate the timeliness of reporting the critical results of
tests and diagnostic procedures.
Goal 3
Improve the safety of using medications.
NPSG.03.04.01
11. Label all medications, medication containers, and other
solutions on and off the sterile field in perioperative and other
procedural settings.
Note: Medication containers include syringes, medicine cups,
and basins.
--Rationale for NPSG.03.04.01--
Medications or other solutions in unlabeled containers are
unidentifiable. Errors, sometimes tragic, have
resulted from medications and other solutions removed from
their original containers and placed into
unlabeled containers. This unsafe practice neglects basic
principles of safe medication management, yet it is
routine in many organizations.
The labeling of all medications, medication containers, and
other solutions is a risk-reduction activity
consistent with safe medication management. This practice
addresses a recognized risk point in the
administration of medications in perioperative and other
procedural settings. Labels for medications and
medication containers are also addressed at Standard
MM.05.01.09.
Element(s) of Performance for NPSG.03.04.01
1. In perioperative and other procedural settings both on and off
the sterile field, label medications and
solutions that are not immediately administered. This applies
even if there is only one medication
being used.
Note: An immediately administered medication is one that an
authorized staff member prepares or
obtains, takes directly to a patient, and administers to that
patient without any break in the process.
13. not the person who will be administering it.
5. Label each medication or solution as soon as it is prepared,
unless it is immediately administered.
Note: An immediately administered medication is one that an
authorized staff member prepares or
obtains, takes directly to a patient, and administers to that
patient without any break in the process.
6. Immediately discard any medication or solution found
unlabeled.
7. Remove all labeled containers on the sterile field and discard
their contents at the conclusion of the
procedure.
Note: This does not apply to multiuse vials that are handled
according to infection control practices.
8. All medications and solutions both on and off the sterile field
and their labels are reviewed by entering
and exiting staff responsible for the management of
medications.
NPSG.03.05.01
Reduce the likelihood of patient harm associated with the use of
anticoagulant therapy.
Note: This requirement does not apply to routine situations in
which short-term prophylactic anticoagulation is used for
preventing venous thromboembolism (for example, related to
procedures or hospitalization).
--Rationale for NPSG.03.05.01--
Anticoagulation therapy can be used as therapeutic treatment
for several conditions, the most common of
15. Report Generated by DSSM
Wednesday, Oct 28 2020
National Patient Safety Goals Effective
January 2021 for the Hospital Program
2. The hospital uses approved protocols and evidence-based
practice guidelines for reversal of
anticoagulation and management of bleeding events related to
each anticoagulant medication.
3. The hospital uses approved protocols and evidence-based
practice guidelines for perioperative
management of all patients on oral anticoagulants.
Note: Perioperative management may address the use of
bridging medications, timing for stopping an
anticoagulant, and timing and dosing for restarting an
anticoagulant.
4. The hospital has a written policy addressing the need for
baseline and ongoing laboratory tests to
monitor and adjust anticoagulant therapy.
Note: For all patients receiving warfarin therapy, use a current
international normalized ratio (INR) to
monitor and adjust dosage. For patients on a direct oral
anticoagulant (DOAC), follow evidence-based
practice guidelines regarding the need for laboratory testing.
5. The hospital addresses anticoagulation safety practices
through the following:
- Establishing a process to identify, respond to, and report
adverse drug events, including adverse
drug event outcomes
- Evaluating anticoagulation safety practices, taking actions to
17. The large number of people receiving health care who take
multiple medications and the
complexity of managing those medications make medication
reconciliation an important safety
issue. In medication reconciliation, a clinician compares the
medications a patient should be using
(and is actually using) to the new medications that are ordered
for the patient and resolves any
discrepancies.
The Joint Commission recognizes that organizations face
challenges with medication reconciliation.
The best medication reconciliation requires a complete
understanding of what the patient was
prescribed and what medications the patient is actually taking.
It can be difficult to obtain a
complete list from every patient in an encounter, and accuracy
is dependent on the patient’s ability
and willingness to provide this information. A good faith effort
to collect this information is
recognized as meeting the intent of the requirement. As health
care evolves with the adoption of
more sophisticated systems (such as centralized databases for
prescribing and collecting
medication information), the effectiveness of these processes
will grow.
This National Patient Safety Goal (NPSG) focuses on the risk
points of medication reconciliation.
The elements of performance in this NPSG are designed to help
organizations reduce negative
patient outcomes associated with medication discrepancies.
Some aspects of the care process that
involve the management of medications are addressed in the
standards rather than in this goal.
These include coordinating information during transitions in
18. care both within and outside of the
organization (PC.02.02.01), patient education on safe
medication use (PC.02.03.01), and
communications with other providers (PC.04.02.01).
In settings where medications are not routinely prescribed or
administered, this NPSG provides
organizations with the flexibility to decide what medication
information they need to collect based
on the services they provide to patients. It is often important for
clinicians to know what medications
the patient is taking when planning care, treatment, and
services, even in situations where
medications are not used.
NPSG.03.06.01
Maintain and communicate accurate patient medication
information.
--Rationale for NPSG.03.06.01--
There is evidence that medication discrepancies can affect
patient outcomes. Medication reconciliation is
intended to identify and resolve discrepancies—it is a process
of comparing the medications a patient is
taking (or should be taking) with newly ordered medications.
The comparison addresses duplications,
omissions, and interactions, and the need to continue current
medications. The types of information that
clinicians use to reconcile medications include (among others)
medication name, dose, frequency, route, and
purpose. Organizations should identify the information that
needs to be collected in order to reconcile current
and newly ordered medications and to safely prescribe
medications in the future.
21. National Patient Safety Goals Effective
January 2021 for the Hospital Program
Goal 6
Reduce patient harm associated with clinical alarm systems.
NPSG.06.01.01
Improve the safety of clinical alarm systems.
--Rationale for NPSG.06.01.01--
Clinical alarm systems are intended to alert caregivers of
potential patient problems, but if they are not
properly managed, they can compromise patient safety. This is a
multifaceted problem. In some situations,
individual alarm signals are difficult to detect. At the same
time, many patient care areas have numerous
alarm signals and the resulting noise and displayed information
tends to desensitize staff and cause them to
miss or ignore alarm signals or even disable them. Other issues
associated with effective clinical alarm
system management include too many devices with alarms,
default settings that are not at an actionable
level, and alarm limits that are too narrow. These issues vary
greatly among hospitals and even within
different units in a single hospital.
There is general agreement that this is an important safety issue.
Universal solutions have yet to be
identified, but it is important for a hospital to understand its
own situation and to develop a systematic,
coordinated approach to clinical alarm system management.
Standardization contributes to safe alarm
22. system management, but it is recognized that solutions may
have to be customized for specific clinical units,
groups of patients, or individual patients. This NPSG focuses on
managing clinical alarm systems that have
the most direct relationship to patient safety.
Note: Additional information on alarm safety can be found on
the AAMI website
https://www.aamifoundation.org/coalitions/clinical-alarm-
systems/complementary-research/.
Element(s) of Performance for NPSG.06.01.01
1. Leaders establish alarm system safety as a hospital priority.
2. Identify the most important alarm signals to manage based on
the following:
- Input from the medical staff and clinical departments
- Risk to patients if the alarm signal is not attended to or if it
malfunctions
- Whether specific alarm signals are needed or unnecessarily
contribute to alarm noise and alarm
fatigue
- Potential for patient harm based on internal incident history
- Published best practices and guidelines
(For more information on managing medical equipment risks,
refer to Standard EC.02.04.01)
3. Establish policies and procedures for managing the alarms
identified in EP 2 above that, at a
minimum, address the following:
- Clinically appropriate settings for alarm signals
- When alarm signals can be disabled
- When alarm parameters can be changed
- Who in the organization has the authority to set alarm
parameters
- Who in the organization has the authority to change alarm
25. Report Generated by DSSM
Wednesday, Oct 28 2020
National Patient Safety Goals Effective
January 2021 for the Hospital Program
NPSG.15.01.01
Reduce the risk for suicide.
Note: EPs 2–7 apply to patients in psychiatric hospitals or
patients being evaluated or treated for behavioral health
conditions as their primary reason for care. In addition, EPs 3–7
apply to all patients who express suicidal ideation
during the course of care.
--Rationale for NPSG.15.01.01--
Suicide of a patient while in a staffed, round-the-clock care
setting is a frequently reported type of sentinel
event. Identification of individuals at risk for suicide while
under the care of or following discharge from a
health care organization is an important step in protecting these
at-risk individuals.
Element(s) of Performance for NPSG.15.01.01
1. For psychiatric hospitals and psychiatric units in general
hospitals: The hospital conducts an
environmental risk assessment that identifies features in the
physical environment that could be used
to attempt suicide; the hospital takes necessary action to
minimize the risk(s) (for example, removal of
anchor points, door hinges, and hooks that can be used for
hanging).
26. For nonpsychiatric units in general hospitals: The organization
implements procedures to mitigate the
risk of suicide for patients at high risk for suicide, such as one -
to-one monitoring, removing objects that
pose a risk for self-harm if they can be removed without
adversely affecting the patient’s medical care,
assessing objects brought into a room by visitors, and using safe
transportation procedures when
moving patients to other parts of the hospital.
Note: Nonpsychiatric units in general hospitals do not need to
be ligature resistant. Nevertheless,
these facilities should routinely assess clinical areas to identify
objects that could be used for self-harm
and remove those objects, when possible, from the area around a
patient who has been identified as
high risk for suicide. This information can be used for training
staff who monitor high-risk patients (for
example, developing checklists to help staff remember which
equipment should be removed when
possible).
2. Screen all patients for suicidal ideation who are being
evaluated or treated for behavioral health
conditions as their primary reason for care using a validated
screening tool.
Note: The Joint Commission requires screening for suicidal
ideation using a validated tool starting at
age 12 and above.
3. Use an evidence-based process to conduct a suicide
assessment of patients who have screened
positive for suicidal ideation. The assessment directly asks
about suicidal ideation, plan, intent, suicidal
or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of a single
28. Goal 15
Introduction to the Universal Protocol for Preventing Wrong
Site, Wrong
Procedure, and Wrong Person Surgery™
The Universal Protocol applies to all surgical and nonsurgical
invasive procedures. Evidence indicates that
procedures that place the patient at the most risk include those
that involve general anesthesia or deep
sedation, although other procedures may also affect patient
safety. Hospitals can enhance safety by correctly
identifying the patient, the appropriate procedure, and the
correct site of the procedure.
The Universal Protocol is based on the following principles:
- Wrong-person, wrong-site, and wrong-procedure surgery can
and must be prevented.
- A robust approach using multiple, complementary strategies is
necessary to achieve the goal of always
conducting the correct procedure on the correct person, at the
correct site.
- Active involvement and use of effective methods to improve
communication among all members of the
procedure team are important for success.
- To the extent possible, the patient and, as needed, the family
are involved in the process.
- Consistent implementation of a standardized protocol is most
effective in achieving safety.
The Universal Protocol is implemented most successfully in
hospitals with a culture that promotes teamwork
and where all individuals feel empowered to protect patient
safety. A hospital should consider its culture
when designing processes to meet the Universal Protocol. In
30. Conduct a preprocedure verification process.
--Rationale for UP.01.01.01--
Hospitals should always make sure that any procedure is what
the patient needs and is performed on the
right person. The frequency and scope of the verification
process will depend on the type and complexity of
the procedure.
The preprocedure verification is an ongoing process of
information gathering and confirmation. The purpose
of the preprocedure verification process is to make sure that all
relevant documents and related information
or equipment are as follows:
- Available prior to the start of the procedure
- Correctly identified, labeled, and matched to the patient’s
identifiers
- Reviewed and are consistent with the patient’s expectations
and with the team’s understanding of the
intended patient, procedure, and site
Preprocedure verification may occur at more than one time and
place before the procedure. It is up to the
hospital to decide when this information is collected and by
which team member, but it is best to do it when
the patient can be involved. Possibilities include the following:
- When the procedure is scheduled
- At the time of preadmission testing and assessment
- At the time of admission or entry into the facility for a
procedure
- Before the patient leaves the preprocedure area or enters the
procedure room
Missing information or discrepancies are addressed before
starting the procedure.
32. January 2021 for the Hospital Program
Introduction to UP.01.02.01
Wrong-site surgery should never happen, yet it is an ongoing
problem in health care that
compromises patient safety. Marking the procedure site is one
way to protect patients; patient
safety is enhanced when a consistent marking process is used
throughout the hospital. Site
marking is done to prevent errors when there is more than one
possible location for a procedure.
Examples include different limbs, fingers and toes, lesions,
level of the spine, and organs. In cases
where bilateral structures are removed (such as tonsils or
ovaries) the site does not need to be
marked.
Responsibility for marking the procedure site is a hotly debated
topic. One position is that since the
licensed independent practitioner is accountable for the
procedure, he or she should mark the site.
Another position is that other individuals should be able to
mark the site in the interests of work flow
and efficiency.
There is no evidence that patient safety is affected by the job
function of the individual who marks
the site. The incidence of wrong-site surgery is low enough that
it is unlikely that valid data on this
subject will ever be available. Furthermore, there is no clear
consensus in the field on who should
mark the site. Rather than remaining silent on the subject of site
marking, The Joint Commission
sought a solution that supports the purpose of the site mark. The
33. mark is a communication tool
about the patient for members of the team. Therefore, the
individual who knows the most about the
patient should mark the site. In most cases, that will be the
person performing the procedure.
Recognizing the complexities of the work processes supporting
invasive procedures, The Joint
Commission believes that delegation of site marking to another
individual is acceptable in limited
situations as long as the individual is familiar with the patient
and involved in the procedure. These
individuals would include the following:
- Individuals who are permitted through a postgraduate
education program to participate in the
procedure.
- A licensed individual who performs duties requiring
collaborative or supervisory agreements with
a licensed independent practitioner. These individuals include
advanced practice registered nurses
(APRNs) and physician assistants (PAs).
The licensed independent practitioner remains fully accountable
for all aspects of the procedure
even when site marking is delegated.
UP.01.02.01
Mark the procedure site.
Element(s) of Performance for UP.01.02.01
1. Identify those procedures that require marking of the incision
or insertion site. At a minimum, sites are
marked when there is more than one possible location for the
procedure and when performing the
35. collaborative agreement or supervisory
agreement with the licensed independent practitioner
performing the procedure (that is, an advanced
practice registered nurse [APRN] or physician assistant [PA]);
who is familiar with the patient; and who
will be present when the procedure is performed.
Note: The hospital's leaders define the limited circumstances (i f
any) in which site marking may be
delegated to an individual meeting these qualifications.
4. The method of marking the site and the type of mark is
unambiguous and is used consistently
throughout the hospital.
Note: The mark is made at or near the procedure site and is
sufficiently permanent to be visible after
skin preparation and draping. Adhesive markers are not the sole
means of marking the site.
5. A written, alternative process is in place for patients who
refuse site marking or when it is technically or
anatomically impossible or impractical to mark the site (for
example, mucosal surfaces or perineum).
Note: Examples of other situations that involve alternative
processes include:
- Minimal access procedures treating a lateralized internal
organ, whether percutaneous or through a
natural orifice
- Teeth
- Premature infants, for whom the mark may cause a permanent
tattoo
UP.01.03.01
A time-out is performed before the procedure.
--Rationale for UP.01.03.01--
36. The purpose of the time-out is to conduct a final assessment that
the correct patient, site, and procedure are
identified. This requirement focuses on those minimum features
of the time-out. Some believe that it is
important to conduct the time-out before anesthesia for several
reasons, including involvement of the patient.
A hospital may conduct the time-out before anesthesia or may
add another time-out at that time. During a
time-out, activities are suspended to the extent possible so that
team members can focus on active
confirmation of the patient, site, and procedure.
A designated member of the team initiates the time-out and it
includes active communication among all
relevant members of the procedure team. The procedure is not
started until all questions or concerns are
resolved. The time-out is most effective when it is conducted
consistently across the hospital.
Element(s) of Performance for UP.01.03.01
1. Conduct a time-out immediately before starting the invasive
procedure or making the incision.
2. The time-out has the following characteristics:
- It is standardized, as defined by the hospital.
- It is initiated by a designated member of the team.
- It involves the immediate members of the procedure team,
including the individual performing the
procedure, the anesthesia providers, the circulating nurse, the
operating room technician, and other
active participants who will be participating in the procedure
from the beginning.
3. When two or more procedures are being performed on the
38. Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 1 15
A New Mindset for Quality and Safety:
The QSEN Competencies Redefine Nurses’
Roles in Practice
I
mproving the quality and safety of
our healthcare system is the most
pressing issue of our time. Since the
Institute of Medicine (IOM) reveal -
ed the magnitude of quality and safe-
ty outcomes in its report, To Err Is
Human: Building a Safer Health System
(IOM, 2000), there has been a grow-
ing series of efforts for improvements,
including changes to health profes-
sions education. In 2003, the IOM
called for a new framework that would
prepare all health professionals with
six core competencies to be able to
deliver patient-centered care through
teamwork and collaboration, with
evidence-based care from continuous
quality improvement, with a mindset
for safety and employing informatics.
These competencies are the founda-
tion to develop and work in cultures
of quality and safety, and change the
mindset from a focus on individual
provider to a system perspective to
improve outcomes. While the compe-
39. tencies are familiar terms, they were
redefined for nurses in 2007 by the
Quality and Safety Education for
Nurses (QSEN) project with a new set
of knowledge, skills, and attitudes that
change how nurses work (Cronenwett
et al., 2007).
Gwen Sherwood
Meg Zomorodi
Continuing Nursing
Education
Gwen Sherwood, PhD, RN, FAAN, is Professor
and Associate Dean for Academic Affairs,
University of North Carolina at Chapel Hill,
School of Nursing, Chapel Hill, NC, and Co-
Investigator, Quality and Safety Education for
Nursing (QSEN). She may be contacted directly
via email at [email protected]
Meg Zomorodi, PhD, RN, CNL, is a Clinical
Associate Professor, University of North Carolina at
Chapel Hill, School of Nursing, Chapel Hill, NC.
Statement of Disclosure: The authors reported
no actual or potential conflict of interest in rela-
tion to this continuing nursing education activity.
Note: Additional statements of disclosure and
instructions for CNE evaluation can be found on
page 23.
This offering for 1.4 contact hours is provided by the American
Nephrology Nurses’
Association (ANNA).
40. American Nephrology Nurses’ Association is accredited as a
provider of continuing nursing
education by the American Nurses Credentialing Center
Commission on Accreditation.
ANNA is a provider approved by the California Board of
Registered Nursing, provider number
CEP 00910.
This CNE article meets the Nephrology Nursing Certification
Commission’s (NNCC’s) continu-
ing nursing education requirements for certification and
recertification.
Copyright 2014 American Nephrology Nurses’ Association
Sherwood, G., & Zomorodi, M. (2014). A new mindset for
quality and safety: The QSEN
competencies redefine nurses’ roles in practice. Nephrology
Nursing Journal, 41(1), 15-
22, 72. Retrieved from
http://www.prolibraries.com/anna/?select=session&
sessionID=2965
Preventable errors are a major issue in health care. The
complexity of health care
requires interactions among numerous providers for any patient
multiple times a day.
Nurses are the constant presence with patients and have an
important role in coordi-
nating the contributions of the myriad of caregivers. Nurses are
also the last line of
defense. Increasingly, it is recognized that nurses need to be
better prepared with quality
and safety competencies to have a leading role in making our
41. healthcare system safer.
This article presents evidence related to quality and safety,
describes the six core compe-
tencies from the Quality and Safety Education for Nurses
(QSEN) project for integration
in nursing practice, describes a practice based on inquiry and
engagement, and presents
a toolkit for developing a new mindset based on new quality and
safety science.
Key Words: Quality and Safety Education for Nurses (QSEN),
quality improve-
ment, patient safety.
Goal
To provide an overview of the role quality and safety
competencies have in making our
healthcare system safer via the Quality and Safety Education for
Nurses project.
Objectives
1. Identify the evidence driving the imperative to improve
healthcare outcomes.
2. Describe applications in practice of the knowledge, skills,
and attitudes for the six com-
petencies defined by the Quality and Safety Education for
Nurses (QSEN) project.
3. Discuss the changes in roles and responsibilities for nurses
when applying the six
QSEN competencies.
This article highlights the evi-
dence driving the imperative to im -
prove healthcare outcomes; describes
42. applications in practice of the knowl-
edge, skills, and attitudes for the six
competencies defined by the QSEN
project; and discusses the changes in
roles and responsibilities for nurses.
The article also includes strategies for
developing a new mindset to achieve
the competencies, with embedded
clinical situations and a case study
related to nephrology nursing to illus-
trate integration of the competencies.
Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 116
A New Mindset for Quality and Safety: The QSEN
Competencies Redefine Nurses’ Roles in Practice
The Imperative to Improve Quality
And Safety
Healthcare professionals, includ-
ing nurses, are well educated and
highly skilled, yet the healthcare sys-
tem continues to be plagued by quali-
ty and safety issues. Healthcare errors
occur at an alarmingly high incidence
and are the eighth leading cause of
death (IOM, 2000; Landrigan, Parry,
Bones, Goldman, & Sharek, 2010).
More people die each year from med-
ical errors than breast cancer or motor
vehicle accidents (Barach & Berwick,
43. 2003). The Institute for Healthcare
Improvement (IHI) (2007) has esti-
mated there are 40,000 incidents of
medical errors every day. At least 1.5
million preventable medication er rors
occur each year in the United States;
this translates to an average of at least
one medication error per day per
patient (Aspen, Walcott, Bootman,
Cronenwett, & the Committee on
Identifying and Preventing Medi -
cation Errors, 2007). Preventable
errors cost the U.S. approximately $17
billion each year (Landrigan et al.,
2010). The latest report card from
Wachter (2010) shows little progress in
the decade following the 1999 report
by the IOM (2000). Nurses, as one of
the largest groups of providers, have
new roles and responsibilities to
improve patient safety and quality.
What education and preparation to
engage nurses as leaders could
improve our systems of care?
Quality and safety are core val-
ues in health care based on the com-
mitment to uphold ethical principles
to do no harm, always safeguard the
patient, and act with ethical comport-
ment (Egan, 2013). Quality is an in -
herent approach to doing good work;
nurses come to work wanting to per-
form good work, but they sometimes
lack the preparation and tools or may
work in systems where good work is
44. not recognized or supported. Evi -
dence supports that nurses want to
work in systems that recognize good
work and uphold a work environ-
ment that supports quality and safety
(IOM, 2004; Manojlovich & DeCicco,
2007; Wong & Cummings, 2007). The
MagnetTM recognition program stan-
dards are consistent with a safety cul-
ture through the focus on quality
improvement, strong leadership, and
interdisciplinary collaboration (Di
Bennedetto et al., 2011; Pischke-Winn,
Stratton, Ferket, & Micek, 2013; Triolo,
2012).
Changing Perspectives
On Quality and Safety
The new science of quality and
safety shifts from prevailing models
focused on individual actions to a
focus on system improvements.
Quality and safety overlap, and each
contributes to the other, but each has
its own body of knowledge, skills, and
attitudes.
Simply put, quality measures
actual performance of a standard pro -
cess or event ( Johnson, 2012), such as
the number and types of patient falls
over a period of time in a particular
setting. These data are compared with
benchmarks in other departments in
45. the same organization and/or with
other similar organizations, or against
an ethical standard of zero occur-
rences. In the case of falls, ethically,
no patient should experience a fall, so
quality improvement efforts are
aimed at zero occurrences.
Safety, on the other hand, is pre-
venting errors and negative outcomes
that happen unrelated to the patient
condition being treated, and again,
the goal is zero occurrences. Safety is
constantly scanning the environment
to prevent mistakes from happening
(Barnsteiner, 2012). The mindset is on
prevention; there is constant aware-
ness of the potential for a patient to
fall, and steps are taken for preven-
tion. The individual action is the
nurse including a reminder to check
on a patient at risk for falls in the
day’s task list; a system design is using
a mattress alarm to alert staff that a
patient at risk for falls has gotten out
of bed unattended.
Safety is the watchful eye that
prevents errors. Quality measures
events and seeks improvements
through quality initiatives.
Safety Culture: A System
Approach
Safety culture is a subset of orga-
46. nizational culture defined by the val-
ues and beliefs about health and safety
evident in the way the organization
lives (Reason & Hobbs, 2003). Safety
culture is the visible evidence of how
individuals and the overall organiza-
tion manage risks and hazards to avoid
damage or losses and achieve their
goals. Safety culture reflects the com-
mon understanding about safety and
emerges from the dynamic reciprocal
interaction among people, tasks, and
systems (Feng, Bobay, & Weiss, 2008).
Other high performance indus-
tries, such as aviation, nuclear power,
and railway, have adopted safety as
an essential standard and changed the
culture that drives their systems to
make safety a priority with the focus
on where the next error could occur
(Roberts, Yu, & van Stralen, 2013).
Health care is adopting methods from
these industries that have produced
dramatic safety improvements. In the
past, health care has focused on the
individual performance and estab-
lished blame for the error, and little
information was shared with patients
and families (Ashpole, 2013). Today,
efforts have been made to shift the
focus in the healthcare system to one
of quality and safety, where errors
(safety) are recognized as a break-
down in processes (quality) and
reported to a central database. Then
47. the errors are investigated to identify
the steps in every related process to
determine where different decisions
or actions could have prevented the
error (Sutcliffe, 2011). The process or
system is then redesigned to mitigate
future occurrences. The mindset is on
preventing errors from happening
through awareness and alertness to
system breakdowns to interrupt the
pathway towards an error (a near
miss).
To illustrate a system approach, a
nurse administered an adult dose of a
high-risk medication to an infant. The
mistake was reported and investigat-
ed by the risk management team to
determine what happened from the
Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 1 17
purchasing department, to the phar-
macy, to the unit, to the medication
administration process. The root
cause analysis (RCA) revealed that
both the pediatric and the adult unit
doses came in similar vials, different
only in the small lettering detailing
the dosage, and both were stored in
adjacent bins. To address this prob-
lem, the bins were relocated and
labeling clarified to reduce the likeli-
48. hood that the wrong vial would be
picked up in a rush. However, the
mindset did not stop there. Additional
organizations that shared benchmark-
ing practices were scanned, revealing
that others had reported a similar mis-
take. Together, the organizations
leveraged the manufacturer to change
the packaging to more clearly distin-
guish the two dosages. Additionally,
there was a search to see if other med-
ications were at similar risk of
misidentification due to similar pack-
aging, thus preventing future errors
from occurring. This process of trans-
parent communication is a key part of
safety culture, so information about
what happened and steps taken to
prevent future occurrences are shared
with patients and families (Sammer,
Lykens, Singh, Mains, & Lackan,
2010). In this scenario, the nurse who
administered the medication was still
accountable, while also updating
her/his knowledge on the evidence-
based standards for safe medication
administration, and system changes
were established to help prevent
future mistakes when human factors
lead to a process breakdown.
A New Mindset to Improve Quality
And Safety: Applying the QSEN
Competencies
Recognizing the need for changes
49. in how nurses are educated to meet
practice demands for quality and safe-
ty, the Quality and Safety Education
for Nurses (QSEN) (www.qsen.org)
project (funded by the Robert Wood
Johnson Foundation) established a
national expert panel to define the six
core competencies established by the
2003 IOM report for integrating a
quality and safety framework for
nursing (Cronenwett et al., 2007). The
panel identified knowledge, skills,
and attitudes essential to achieve each
competency stated as objectives for
integration into curricula (Cronenwett
et al., 2007) and are now part of
national nursing education curricula
standards. The definition for each com-
petency with a summary of expecta-
tions for practice are shown in Table 1;
all 162 knowledge, skill, and attitude
statements are available online (www.
qsen.org), in Cronenwett et al. (2007),
and in Sherwood and Barnsteiner
(2012). Graduate competencies reflect
higher order performance expected
of graduate nurses (Cronenwett et al.,
2009) and are embedded in the
American Association for Colleges of
Nursing (AACN) essentials for
Master’s and DNP education; they
were updated in 2012 (AACN, 2012).
Applying the QSEN
Competencies in Practice
50. The competencies defined by the
QSEN project apply for all of nursing
practice: patient-centered care, team-
work and collaboration, evidence-
based practice, quality improvement,
safety, and informatics (see Table 1).
Each competency is described for
applications in nursing practice with
particular application in nephrology
nursing.
Patient-centered care. Patient-
centered care is demonstrated through
respect, response, and clear commu-
nication, and always asking patients
their preference for which name they
wished to be called (Walton &
Barnsteiner, 2012). Patient- and family-
centered care was first defined by the
Picker Institute as improving health
care through the eyes of the patient
(Gerteis, Edgman-Levitan, Daley, &
Delbanco, 1993). When patients and
their families are involved in making
decisions about their care, the focus
shifts from “doing to” to “doing with.”
When patients and families are treat-
ed as members of the care team, they
can become safety allies, thus pre-
venting errors. For example, patients
may alert clinicians when care is not
according to their usual routine or by
noticing a different medication. Care
planning is based on cultural aware-
51. ness and assessments to know patient
values, beliefs, and preferences.
Evidence continues to raise questions
about policies and procedures that
separate patients and families, partic-
ularly visiting hours.
Patient-centered approaches to
pain management is an area of partic-
ular concern to nephrology nurses to
know patient preferences and goals
for managing pain, providing patient-
appropriate education, and knowing
when to administer pharmacologic
agents or use complementary thera-
pies. In the hospital, practical applica-
tions include communication using
white boards in the patient’s room to
identify persons caring for the patient,
daily care goals, and scheduled treat-
ments. Patients and their families like-
wise use the boards to record infor-
mation or register questions for the
care team. Some units have provided
long-term patients and their families
with small journals to maintain a
health history, and keep records of
treatments, medications, or other
health information.
Teamwork and collaboration.
Communication and collaboration
are at the root of teamwork, but the
education of health professionals is by
individual discipline, both formally
and in continuing education (Disch,
52. 2012). Thus, there is little interprofes-
sional contact until new graduates are
thrust into practice settings to work
closely together, often under stressful
conditions. Between 1995 and 2005,
ineffective communication and break-
downs in working together was the
root cause of 66% of healthcare errors
(Hughes, 2008). Adverse drug events
most often occur at transition points
in care or during handoffs, from one
provider to another (Hughes, 2008).
Teamwork and collaboration are
essential for coordinating complex
care involving several health care dis-
ciplines (Simmons & Sherwood, 2010),
which is especially important for
nephrology patients whose care may
involve multiple providers. Knowing
the roles and responsibilities of other
team members can help nurses navi-
gate the complicated web of commu-
Nephrology Nursing Journal January-February 2014 Vol. 41,
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A New Mindset for Quality and Safety: The QSEN
Competencies Redefine Nurses’ Roles in Practice
nication and hierarchy so prevalent in
health care (Disch, 2012). Participa -
ting in interprofessional rounds that
include patients and families helps to
53. coordinate information, set daily care
goals, and manage schedules for the
various treatments. Nurses need to
know how to speak up when care is
compromised (see Table 2), and to do
this, must have organizational support
to back them up (Manojlovich &
DeCicco, 2007; Wong & Cummings,
2007). Teamwork requires flexible
leadership that shifts to match expert-
ise and role of the team members.
TeamSTEPPS® is an evidence-
based curriculum for developing
teamwork to improve quality and
safety (Agency for Healthcare Research
& Quality [AHRQ], n.d.). Research
shows that the risk of serious adverse
events is reduced when team training
has been implemented (Hughes,
2008). The knowledge and skills
taught in TeamSTEPPS are often
embedded in simulation (Carswell,
2013). Standardized communications
(see Table 2) help reduce risks during
transitions and handoffs, reduce
reliance on memory, assure that criti-
cal information is shared, and help
team members speak up when they
see safety hazards.
Evidence-based practice. Patient
care is based on evidence-based prac-
tice standards and industry best stan-
54. Table 1
Quality and Safety Competencies Defined by the QSEN Project
with Summary Expectations for Nurses
Derived from the Knowledge, Skills, and Attitudes
Competency Definition Examples of Expectations
Patient-centered
care
Recognize the patient or designee as the source of
control and full partner in providing compassionate
and coordinated care based on respect for
patient’s preferences, values, and needs.
• Provides nursing care based on individual and family
needs and preferences.
• Applies cultural awareness in the provision of health
care services, including aspects of nutrition, spiritual
resources, and patient education.
• Uses effective interpersonal communication skills.
Teamwork and
collaboration
Function effectively within nursing and inter-
professional teams, fostering open communication,
mutual respect, and shared decision-making to
achieve quality patient care.
• Recognizes own strengths and limitations as a team
member.
55. • Communicates and collaborates effectively in
intranursing and interprofessional teams to achieve
best outcomes for the patient.
• Treats patient and family as active team members.
Evidence-based
practice
Integrate best current evidence with clinical
expertise and patient/family preferences and
values for delivery of optimal health care.
• Uses current evidence based standards in care
interventions.
• Evaluates evidence to determine best practices.
• Determines deviations from standards to
accommodate patient beliefs and preferences.
Quality
improvement
Use data to monitor the outcomes of care
processes and use improvement methods to
design and test changes to continuously improve
the quality and safety of health care systems.
• Identifies processes or issue for improvement.
• Assists with measurement of the process or issue
against benchmarks.
• Can identify good practice.
• Apply process improvement strategies to improve
56. process or issue.
Safety Minimize risk of harm to patients and providers
through both system effectiveness and individual
performance.
• Applies new safety science for awareness of
breakdowns in processes.
• Recognizes and reports errors and near misses that
compromise patient safety.
• Participates in analysis of adverse events and near
misses for root cause analysis.
Informatics Use information and technology to communicate,
manage knowledge, mitigate error, and support
decision-making.
• Applies skills in data and information management to
access latest evidence.
• Uses decision support tools appropriately.
• Records data and patient information in electronic
health records.
Source: Adapted from Cronenwett et al., 2007.
Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 1 19
dards (Tracey & Barnsteiner, 2012).
57. Nephrology nurses need to know the
standards of care that guide their
practice and recognize those interven-
tions that carry high risk, such as
managing all types of catheters, pre-
venting infections, and maintaining
fluid balance (Gomez, 2011). In
patient-centered care, nurses recog-
nize when to deviate from standards
to consider patient preferences, val-
ues, and beliefs within an evidence-
based approach. Nurses who practice
from a spirit of inquiry with reflection
on care delivered will use skills in
informatics to seek current evidence
to determine best practices and clari-
fy care decisions. They monitor their
practice, reflecting on when changes
are needed, and formulate clinical
questions to seek new evidence so
practice is constantly developing and
improving.
Quality improvement. The
spirit of inquiry promotes an attitude
of continuously improving care every
day with every patient ( Johnson,
2012). Quality improvement first
measures variance between ideal and
actual care, and then implements
strategies to close any gaps. Nurses
use quality improvement tools and
informatics to seek evidence and
measure care outcomes, as well as
benchmark data to assess current
practice. The American Nephrology
58. Nurses’ Association’s publication,
Applying Continuous Quality Improve -
ment in Clinical Practice, is a resource
for information on quality improve-
ment tools and applications in neph -
rology nursing (Axley & Robbins,
2009). Nurses benchmark in their
local system as well as against nation-
al standards. The National Database
of Nursing Quality Indica tors from
the American Nurses Association
(n.d.) is one example of a benchmark-
ing source where surgical site infec-
tions, pain assessment, pressure ulcer
development, and falls can be exam-
ined.
Safety. Safety is the effort to min-
imize the risk of harm to patients and
providers by improving both system
effectiveness and individual perform-
ance (Barnsteiner, 2012). Every nurse,
and in fact, every employee and
patient, is responsible for safety. A
safety culture, discussed earlier, en -
courages asking how one’s actions
affect patient risk, where the next
error is likely to occur, and how to
prevent near misses, and there is a
reporting system for collecting infor-
mation on adverse and sentinel events.
Many goals on the annual list of
National Patient Safety Goals from
The Joint Commission (2013) are rel-
evant for nephrology nursing, such as
59. medication safety, healthcare-associ-
ated infections, central line-associated
bloodstream infections, pain manage-
ment, responding to changes in
patient condition, communication,
and handoffs.
Standardized communication,
described in Table 2, can assure that
essential information is shared with
the correct providers to overcome
forgetfulness or lack of attention.
Human factors consider the mix of
people, tasks, and the environment;
conditions in the environment, such
as distractions, interruptions, and
other environmental conditions,
impact error potential. Training can
increase skills in situation monitoring,
environmental scanning, and shared
decision-making. Working together,
nurses can develop strategies to better
manage task overloads, staff fluctua-
tions, and interruptions.
Informatics. Informatics is a crit-
ical skill for achieving all the compe-
tencies by helping manage care.
Technology, such as electronic health
records, helps communicate care
coordination by recording and shar-
ing information about a patient
(Warren, 2012). Other applications
Table 2
60. Standardized Communication Strategies from TeamSTEPPS
(www.AHRQ.gov)
Strategy Application
SBAR: Used to
develop and refine
communication.
Situation: A statement of what is happening right now
that needs attention.
Background: Information that puts the situation into
context and explains the circumstances that have led to
the situation.
Assessment: Conveys the communicators’ thoughts
about the problem.
Recommendation: What should be done to correct the
problem, when and by whom.
CUS: Used to raise
safety concerns,
moves to next
statement if no action.
C: I am concerned.
U: I am uncomfortable.
S: I think this is a safety issue. (If no action, next step is to
go up the chain of command for help.)
Check back: Used to
clarify communication.
Repeat back an order, a request, or other critical
information to be sure there was clear communication.
61. Briefings: Plan care? What is the most important thing this
patient needs?
What are safety issues?
What are the benchmarks and/or evidence for the care
interventions?
Huddles: Problem
solve or clarify
strategy, get everyone
on the same page.
What is priority?
What else could it be?
What could we do differently?
What was done well?
Debriefing: Review
and feedback.
What did not go well?
What could be done differently next time?
Nephrology Nursing Journal January-February 2014 Vol. 41,
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A New Mindset for Quality and Safety: The QSEN
Competencies Redefine Nurses’ Roles in Practice
Figure 1
Applying the QSEN Competencies: A Case Study
The following unfolding case study provides an exemplar of
integrating quality and safety in nephrology nursing and poses a
number of provocative questions about the patient’s experience.
62. The case study is most effective when discussed with nurses,
physicians, and others on the care team to identify opportunities
for safety interventions and for quality improvement.
Mr. Orange is a 45-year-old African-American male who
has been on hemodialysis for the past six months using a cen-
tral venous catheter access following a failed kidney transplant
with chronic allograft nephropathy. His history includes high
blood pressure, diabetes, and allergy to penicillin.
Today, he wants his 10-year-old daughter to remain with
him during his treatment because his wife could not miss any
more days of work. The clinic is crowded, and you are con-
cerned about the presence of a child in the treatment area; clin-
ic policy prevents children from accompanying patients. Yet, it
is
obviously very important to Mr. Orange that his daughter
remains with him, and she is providing distraction from the dis-
comfort of his treatment. You recently read an article that chal-
lenged visiting rules, with evidence that patients benefit from
having their family member with them, and there is no impact
on
infection rates or disruption to staff when they are provided
space to be with their loved one. As you talk to Mr. Orange
about
his diet, his daughter becomes engaged in the information you
are presenting, and begins a conversation with her father that
helps you to better understand his attitudes towards his diet, an
important aspect of his care plan.
• What stands out in this situation?
• What actions are consistent/inconsistent with patient-cen-
tered care?
• What practice implications or quality improvement projects
come to mind when examining this scenario?
63. Coordinating Mr. Orange’s care requires collaboration
among several specialty physicians, including the transplant
team, physical therapy, social work, and nutritional services.
Appointments in the clinic are a careful scheduling balance with
each provider to coordinate treatment plans.
Prior to initiation of the hemo dialysis treatment, Mr. Orange
mentions there was some blood in the small amount of urine he
passed before coming to the dialysis facility today. As part of
your pre-treatment assessment, you palpate the area of his
transplanted kidney in his iliac fossa, and he squirms as you
apply pressure and admits that it is tender to palpation. You
recall that his im munosuppression has been tapered, and he is
only on a minimal dose of alternate day immunosuppressive
therapy.
• What stands out? What are priorities? Why, and what are
alternative approaches?
Mr. Orange has now been admitted to the hospital for fur-
ther assessment, and it is determined he requires a transplant
nephrectomy due to more active rejection superimposed on the
chronic allograft nephropathy in the presence of reduced
immunosuppression. He has just been admitted to Room 6222
from the recovery room. The nurse, a new graduate, is taking
the
vital signs as ordered every 15 minutes as per protocol of a new
admission. He notices the patient’s blood pressure has fallen
slightly (118/70). Concerned, he pages the resident. When the
resident calls back, the nurse reports the blood pressure to her.
The resident informs the nurse that this is a normal blood pres -
sure and says to not worry. An hour later, the nurse notices that
Mr. Orange is growing agitated and complaining of belly pain.
The nurse checks the blood pressure and notices that it is it is
lower (90/68). The nurse pages the resident.
64. • What stands out?
• What is the most important action to take? Why?
• What are alternatives?
• How should the nurse communicate with the resident?
The resident informs the nurse that the patient’s blood pres-
sure is lower due to his medication. The nurse, although not
con-
vinced, does not push the issue further. As a new graduate, he
is hesitant to challenge the response. The nurse returns to room
6222 and finds Mr. Orange doubled over in pain and growing
increasingly pale. The nurse once again pages the resident and
waits for 15 minutes by the phone. While waiting for the
resident
to call him back, the nurse returns to room 6222 to take the next
set of vital signs. The patient is unresponsive.
• What stands out?
• What stands out in the scenario?
• What is the priority? Why? What evidence supports this?
• What are alternatives, what else could it be?
• What went well in the case and what could have been
improved?
Discuss aspects of the case related to each of the compe-
tencies: patient centered care, teamwork and collaboration, evi -
dence base practice, quality improvement, safety and informat-
ics.
• How do nurses and other care givers, especially physicians,
deal with disagreements in patient status?
• What are lessons to prevent future occurrences?
include safety alerts for the need for
action, decision support tools, litera-
ture searches for the latest evidence,
65. and management of quality improve-
ment data and strategies. It is impor-
tant that nurses participate in design-
ing applications, making decisions on
purchases, and developing training
materials on using information sys-
tems and patient related technology.
Engagement and Inquiry:
Developing a Quality Safe Practice
Investment in safety is demon-
strated through engagement and in -
quiry. Nurses who bring attention and
mindfulness to their work engage and
focus on each patient, notice break-
downs in care processes and seek solu-
tions, employ best practices, and
participate in lifelong learning
(Sherwood, 2012). Engaged nurses
develop a mindset for safety, use situ-
Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 1 21
ation monitoring to scan the environ-
ment for contextual factors that influ-
ence actions, and watch each other’s
backs to provide mutual support
when needed. Engaged nurses prac-
tice from a spirit of inquiry and ask
questions about their actions, if it is
66. evidence-based or best practice
(Armstrong & Sherwood, 2012). They
recognize safety issues in work-
arounds when standard operations
break down and act to prevent error,
know how to employ continuous
quality improvement to call a team
meeting to address failures in the sys-
tem and together create new process-
es, and work with the organization in
seeking system-based solutions rather
than relying on individual perform-
ance and skill. Engaged nurses are
more satisfied from doing work well,
which leads to higher satisfaction and
longer retention, and contributes to a
healthy work environment (Armstrong,
Laschinger, & Wong, 2009).
A Tool Kit to Develop
A Quality and Safety Mindset
How do nurses initiate a practice
based on quality and safety? What
tools help with the transformation?
Engaged nurses plan their work
beyond mere memorization of facts
or completing a task list; nurses can
learn from experiences to synthesize
and apply knowledge in advancing
their practice. This is the process of
inquiry in action: asking questions
about their work promotes continu-
ous learning from accumulated expe-
riences through reflection informed
by didactic knowledge. Tanner’s
67. (2006) clinical judgment model helps
nurses understand how they make
informed decisions in practice. They
notice what is happening, interpret the
meaning and significance, respond in
meaningful evidence based ways, and
reflect on what happened to be able to
improve decision making in the future.
Analyzing case studies, particu-
larly with other disciplines, is an effec-
tive strategy to reframe events and
encourage a spirit of inquiry to exam-
ine what happened, distinguish good
care from compromised care, discuss
conflicting ethical situations, examine
cultural sensitivity, share knowledge,
learn how to provide and accept feed-
back, and promote professional
development. Cases can be used for
both low-fidelity (role play) or high-
fidelity (computerized mannequins)
simulation to be able to practice
teamwork and communication, nego-
tiate problem solving, improve skills,
apply evidence-based best practices,
and increase awareness of the poten-
tial for error. Briefings, huddles, and
debriefings help manage care, keep
everyone on the same page, and learn
from experience (see Table 2).
Reflective practice is the founda-
tion for analyzing unfolding case stud-
ies or simulations. Reflection is a sys-
68. tematic way of thinking about one’s
actions and responses to improve future
actions and responses (Sherwood &
Horton-Deutsch, 2012). It is a change
process that incorporates experiential
learning by considering what one
knows, believes, and values within
the context of an event. It is also a
personal growth strategy to help nurs-
es cope with the emotional labor of
nursing to make sense of events.
Reflection reframes the situation,
leading to feelings of satisfaction with
work. Reflection can help nurses cope
with confusing workforce issues and
the complicated context of health
care that depletes energy and motiva-
tion. Reflective practice is a habit of
the mind that helps develop profes-
sional maturity through the continued
development of practice knowledge,
constant quality improvement and
attention to safety, and renewal of the
human spirit.
Summary
There are always competing pri-
orities that challenge practice. New
definitions of the six quality and safe-
ty competencies developed by the
QSEN project are transforming nurs-
ing education and practice. Case story
analysis and reflective practice can
promote nurse learning to help devel-
op a new mindset and achieve behav-
69. ior change (see Figure 1). Nurses have
important roles in redesigning health-
care delivery to assure that it is
patient-centered, delivered by inter-
professional teams, based on evi-
dence-based standards with continu-
ous quality im provement, in a culture
of safety, and using informatics. With
a mindset for quality and safety, nurs-
es engage in their work with the
patient as the focus, encourage
inquiry, apply evidence-based stan-
dards and interventions, investigate
outcomes and critical incidents from a
system perspective, and reflect on sit-
uations in their work to continuously
seek to improve care.
References
Agency for Healthcare Research and
Quality (AHRQ). (n.d.). Team -
STEPPS® tools. Rockville, MD:
Author. Retrieved from http://www.
ahrq.gov/legacy/teamsteppstools/ind
ex.html
American Association for Colleges of
Nursing (AACN). (2012). QSEN educa-
tion consortium: Graduate-level QSEN
competencies, knowledge, skills and atti-
tudes. Retrieved from http://www.
aacn.nche.edu/faculty/qsen/compe-
tencies.pdf
70. American Nurses Association. (n.d.).
National database of nursing quality indi-
cators. Silver Spring, MD: Author.
Retrieved from http://www.nursing
w o r l d . o r g / R e s e a r c h -To o l k i t /
NDNQI
Armstrong, G., & Sherwood, G. (2012).
Reflection and mindful practice: A
means to quality and safety. In G.
Sherwood & S. Horton-Deutsch (Eds.),
Reflective practice: Transforming education
and improving outcomes (pp. 21-40).
Indianapolis: Sigma Theta Tau Press.
Armstrong, K., Laschinger, H.K.S., &
Wong, C. (2009). Workplace empow-
erment and Magnet hospital charac-
teristics as predictors of patient safety
climate. Journal of Nursing Care Quality,
24(1), 55-62.
Ashpole, L. (2013). Creating a just culture:
A nonpunitive approach to medical
errors. In B. Youngberg (Ed.), Patient
safety handbook (2nd ed., pp. 169-178).
Burlington, MA: Jones & Bartlett.
Aspen, P., Walcott, J., Bootman, L.,
Cronenwett, L., & the Committee on
Identifying and Preventing Medica -
tion Errors. (2007). Identifying and pre-
venting medication errors. Washington,
DC: National Academies Press.
71. Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 122
A New Mindset for Quality and Safety: The QSEN
Competencies Redefine Nurses’ Roles in Practice
Axley, B., & Robbins, K.C. (Eds.). (2009).
Applying continuous quality improvement
in clinical practice (2nd ed.). Pitman,
NJ: American Nephrology Nurses’
Association.
Barach, P., & Berwick, D. (2003). Patient
safety and the reliability of health
care systems. Annals of Internal
Medicine, 138, 997-998.
Barnsteiner, J. (2012). Safety. In G.
Sherwood & J. Barnsteiner (Eds.),
Quality and safety in nursing: A compe-
tency approach to improving outcomes
(pp. 149-169). Hoboken, NJ: Wiley-
Blackwell.
Carswell, K. (2013). Using simulation to
advance patient safety. In B.
Youngberg (Ed.), Patient safety hand-
book (2nd ed., pp. 495-504).
Burlington, MA: Jones & Bartlett.
Cronenwett, L., Sherwood, G., Barnsteiner,
J., Disch, J., Johnson, J., Mitchell, P.,
… Warren, J. (2007). Quality and safe-
ty education for nurses. Nursing
Outlook, 55(3), 122-131.
72. Cronenwett, L., Sherwood, G., Pohl, J,
Barnsteiner, J., Moore, S., Taylor
Sullivan, D., … Warren, J. (2009).
Quality and safety education for
advanced practice nursing practice.
Nursing Outlook, 57(6), 338-348.
Di Benedetto, A., Pelliccia, F., Moretti, M.,
d’Orsi, W., Starace, F., Scatizzi, L., …
Marcelli, D. (2011). What causes an
improved safety climate among the
staff of a dialysis unit? Report of an
evaluation in a large network. Journal
of Nephrology, 24(5), 604-612.
Disch, J. (2012). Teamwork and collabora-
tion. In G. Sherwood & J.
Barnsteiner (Eds.), Quality and safety
in nursing: A competency approach to
improving outcomes (pp. 91-112).
Hoboken, NJ: Wiley-Blackwell.
Egan, E. (2013). The role of ethics and
ethics services in patient safety. In B.
Youngberg (Ed.), Patient safety hand-
book (2nd ed., pp. 551-560).
Burlington, MA: Jones & Bartlett.
Feng, X., Bobay, K., & Weiss, M. (2008).
Patient safety culture in nursing: A
dimensional concept analysis. Journal
of Advanced Nursing, 63(3), 310-319.
Gerteis, M., Edgman-Levitan, S., Daley,
J., & Delbanco, T.L. (Eds.). (1993).
73. Through the patient’s eyes: Under -
standing and promoting patient-centered
care. San Francisco: Jossey-Bass.
Gomez, N. (Ed.). (2011). Nephrology nurs-
ing: Scope and standards of practice (7th
ed.). Pitman, NJ: American Neph -
rology Nurses’ Association.
Hughes, R.G. (2008). Tools and strategies
for quality improvement and patient
safety. In R.G. Hughes (Ed.), Patient
safety and quality: An evidence-based hand-
book for nurses (vol. 3, pp. 1-40).
Rockville, MD: Agency for Health care
Research and Quality. Retrieved from
http://www.ahrq.gov/qual/nurses
hdbk
Institute for Healthcare Improvement (IHI).
(2007). Protecting 5 million lives from
harm. Cambridge, MA: Author.
Retrieved from http:/www.ihi.org/
IHI/Programs/campaign
Institute of Medicine (IOM). (2000). To err is
human: Building a safer health system.
Washington, DC: National Academy
Press. Retrieved from http://www.
iom.edu/ Reports/1999/To-Err-is-
Human-Building-A-Safer-Health-
System.aspx
Institute of Medicine (IOM). (2003). Health
professions education: A bridge to quality.
Washington, DC: The National
74. Academies Press. Retrieved from
h t t p : / /w w w. i o m . e d u / Re p o r t s /
2003/Health-Professions-Education-A-
Bridge-to-Quality.aspx
Institute of Medicine (IOM). (2004). Keeping
patients safe. Washington, DC: The
National Academies Press. Retrieved
from http://www.iom.edu/Reports/
2 0 0 3 / K e e p i n g - P a t i e n t s - S a f e -
Transforming-the-Work-Environment-
of-Nurses.aspx
Johnson, J. (2012). Quality improvement. In
G. Sherwood & J. Barnsteiner (Eds.),
Quality and safety in nursing: A competen-
cy approach to improving outcomes (pp.
113-132). Hoboken, NJ: Wiley-
Blackwell.
The Joint Commission. (2013). National
patient safety goals. Chicago: Author.
Retrieved from http://www.jointcom-
mission.org/standards_information/np
sgs.aspx
Landrigan, C.P., Parry, G.J., Bones, A.D.,
Goldman, D.A., & Sharek, P.J. (2010)
Temporal trends in rates of patient
harm resulting from medical care. New
England Journal of Medicine. 363, 2124-
2134.
Manojlovich, M., & DeCicco, B. (2007).
Healthy work environments, nurse-
physician communication, and
75. patients’ outcomes. American Journal of
Critical Care, 16(9), 536-543.
Pischke-Winn, K., Stratton, K., Ferket, K., &
Micek, W. (2013). Supporting a culture
of safety: The Magnet recognition pro-
gram. In B. Youngberg (Ed.), Patient
safety handbook (2nd ed., pp. 393-424)
Burlington, MA: Jones & Bartlett.
Reason, J., & Hobbs, A. (2003). Managing
maintenance error: A practical guide.
Burlington, VT: Ashgate Publishing
Company.
Roberts, K., Yu, K.,. & van Stralen, D.
(2013). Patient safety is an organiza-
tional systems issue: Lessons from a
variety of industries. In B. Youngberg
(Ed.), Patient safety handbook (2nd ed.,
pp. 143-156) Burlington, MA: Jones
& Bartlett.
Sammer, C.E., Lykens, K., Singh, K.P.,
Mains, D.A., & Lackan, N.A. (2010).
What is patient safety culture? A
review of the literature. [Meta-
Analysis Review]. Journal of Nursing
Scholarship, 42(2), 156-165.
Sherwood, G. (2012). The imperative to
transform education to transform
practice. In G. Sherwood & J.
Barnsteiner (Eds.), Quality and safety
in nursing: A competency approach to
improving outcomes (pp. 191-210).
76. Hoboken, NJ: Wiley-Blackwell.
Sherwood, G., & Barnsteiner, J. (Eds.),
(2012). Quality and safety in nursing: A
competency approach to improving out-
comes. Hoboken, NJ: Wiley-Blackwell
Sherwood, G., & Horton-Deutsch, S.
(Eds.) (2012). Reflective practice:
Transforming education and improving
outcomes. Indianapolis, IN: Sigma
Theta Tau Press.
Simmons, D., & Sherwood, G. (2010).
Neonatal intensive care unit and
emergency department nurses’ des -
criptions of working together: Build -
ing team relationships to improve
safety. Critical Care Nursing Clinics of
North America, 22 (2), 253-260.
Sutcliffe, K.M. (2011). High reliability
organizations (HROs). Best Practice
Research Clinical Anaesthesiology, 25(2),
133-144. doi:10.1016/j.bpa.2011.03.001
Tanner, C.A. (2006). Thinking like a
nurse: A research based model of
clinical judgment in nursing. Journal
of Nursing Education, 45(6), 204-211.
Tracey, M.F., & Barnsteiner, J. (2012).
Evidence based practice. In G.
Sherwood & J. Barnsteiner (Eds.),
Quality and safety in nursing: A compe-
tency approach to improving outcomes
77. (pp. 133-148). Hoboken, NJ: Wiley-
Blackwell.
Triolo, P. (2012). Creating cultures of
excellence: Transforming organiza-
tions. In G. Sherwood & J.
Barnsteiner (Eds.), Quality and safety
in nursing: A competency approach to
improving outcomes (pp. 305-322).
Hoboken, NJ: Wiley-Blackwell.
continued on page 72
Nephrology Nursing Journal January-February 2014 Vol. 41,
No. 1 23
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A New Mindset for Quality and Safety: The QSEN
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