Accreditation Standards

1.      What did I expect to learn about this topic before beginning the unit?

Accreditation is an important aspect of healthcare. I was excited to learn more about what standards are out there for facilities and what guidelines they go by.

2.      What I actually learned:

      It was really beneficial to read more and learn about the HCAHPS scores. I was actually really surprised about the large influence nurses have on many of the questions. I would say we have influence over most of the questions which makes sense. Nurses spend the most time with the patient and I think the patient’s overall experience is really dependent upon the patient’s nurses because that is who and what they will really remember.

      The case study helped me learn what a sentinel event really is. I realized that sentinel events can’t always be prevented but there are guidelines and precautions/rules to follow to help prevent them from happening. I think it’s always important to know facility policies/expectations as well as to know my resources so I can use them in emergent situations. I also realized how important it is to report sentinel events because data and research is how the medical field has been able to create rules and make changes based on what is happening in daily practice.

      The discussion helped me realize how important those patient safety goals are. It was difficult for our group to come to a consensus because each of the national patient safety goals are important. However, implementing the basics such as correctly identifying the patient and hand hygiene can also help prevent others from occurring. I feel that all the patient safety goals are intertwined and influence the others.

3.      My feelings/experiences from the individual and team activities:

      I enjoyed this final week and felt that the discussion was a good one, especially because it was difficult to come to a consensus. It allowed for us to really think and explore reasons behind that.

4.      How I will utilize the information learned in my nursing practice:

      I want to always remember HCAPS surveys and realize that every interaction I have with a patient can either improve the score or lower it. I will do my best to always prevent sentinel events and take action if one does occur. I will follow the patient safety goals and work on hand hygiene, identifying patients, preventing medication errors as well as infection.

5. My personal feelings about the material covered:

Thought this was important to learn about as we end the semester and continue with our jobs. These are concepts that are very relevant and applicable to the real world. We should always be focusing on accreditation and work to improve patient outcome and experience. 

Patient Safety Application

1.      What did I expect to learn about this topic before beginning the unit?

I was expecting to learn how I can apply patient safety concepts to my daily practice. I was interesting in learning how everything was going to come together.

2.      What I actually learned:

The case study this week allowed me to learn about the error disclosure process. I guess I didn’t realize what sort of an issue this is for patients, families, and clinicians. I didn’t really think about the fear physicians may have about embarrassment and malpractice lawsuits for errors made. It makes sense that this would be a worry just like I have some of those same worries as a nurse. But I learned that it is better to be open and honest with patients. Some may choose to go the lawsuit direction but if that is the case then at least you have been completely open and honest and that does look positive in your case. I am happy that things are changing and there are organizations out there to help clinicians and be there for support when adverse events or traumatic events happen. This is a field of work that is unique and we deal with life and death situations every single day. That is not normal. We need to have support.

The discussion reminded me of importance of following policies and procedures and helped me decide what to do when I see other coworkers not abiding by these policies. It is important to always treat and approach others with respect but being willing to take the steps necessary to help them correct their habits and use superiors if necessary.

The article I found for the literature search was unique but I was able to see how patient safety became the driving force for a change in procedure and standardization of care.

3.      My feelings/experiences from the individual and team activities:

I enjoyed the assignments this week. I think reading about a case study like we had this week was important for us as nurses to realize what happens when errors occur and how it should be disclosed to patients as well as barriers to that disclosure. I think the discussion was successful and my group was able to come to a consensus about how to handle the situation.

4.      How I will utilize the information learned in my nursing practice:

I can remember these things and always have patients at the center of care. By doing this, full disclosure and open communication with them should be natural. It is also important to seek out what resources I have as a nurse and IMC if I need debriefing or just someone to talk to about traumatic events.

5. My personal feelings about the material covered:

Great material for the end of the semester! 

Creating a Culture of Safety

1.  What did I expect to learn about this topic before beginning the unit?
I expected to learn about how we as nurses can continue to maintain that culture of safety. What things I can do each day to keep myself safe, my coworkers safe, and my patients safe. This past week has been interesting at work regarding safety. A code green was called because of a patient who suffered from a TBI. It was a scary situation for many of us.

2.   What I actually learned:

       The discussion brought about some bad feelings in me. I was angry with the fact that the physician would not listen to the RN. I hope this never happens to me but I’m sure it will. In that moment, I have to take action in order to keep that patient safe. I’m glad I was able to discuss with my classmates what options we have. A culture of safety is created by utilizing the chain of command and other team members for support whether that is having the charge RN give pain meds to a patient you are unable to get to or for an insulin double check. It all helps with safety.

       The case study was another one that was so interesting and heartbreaking to learn about. Again, safety was an issue with this young boy who passes away. Members of the team were not communicating with the family, no clarification was ever done, and the possible complications and sometimes common complications of that procedure were never even considered. Education was not done or given to the family and the doctors and nurses really needed to brush up on this. Safety was compromised because members of the care team made a lot of simple mistakes.

       The critical thinking exercise helped me to understand that just because something has been done for a “long time” doesn’t mean it is the best. This semester the focus has been on EBP in some of my other classes. I think this is such an important thing to learn about and realize that I can make a difference, I can implement change, and I can use EBP in my practice as a nurse. EBP does affect safety. Most of the times, EBP is the safest practice.

3.  My feelings/experiences from the individual and team activities:

      I learned a lot about safety and creating a culture of safety this week. It was very impactful for me. Our discussion went well this week and we were all able to decide on what should be done in that situation. It is good to be able to use teamwork even though we are taking classes online.

4. How I will utilize the information learned in my nursing practice:

      Like I have previously stated, I have realized how I am able to create that culture of safety as a nurse. I can use EBP every day , be a patient advocate, use my resources, use the chain of command when/if necessary, and always trust myself and my instincts. This is a good reminder for me.

5. My personal feelings about the material covered:

Safety is always a great thing to be reminded of and learn about. I like the idea of creating a culture of safety. I think that is a very powerful phrase and something that can be implemented no matter where someone works. 

Errors and Near Misses

1.  What did I expect to learn about this topic before beginning the unit?
When I read the topic was “Errors and Near Misses” I was worried. Making a mistake always scares me especially as a new nurse. I was hoping to learn more about ways to prevent these errors and near misses.

2.   What I actually learned:

The case study this week put a pit in my stomach as I was reading it. I definitely felt like that was the main focus this week and for good reason. I think it is so beneficial to read about situations like this in order to learn from it. I’m glad there are others who have gone before me and have made those mistakes to hopefully I will never do the same thing. I also realized that it is beneficial for the health industry when things like this happen and changes are made to improve patient safety.

Human error is something that will never go away. It will never and can’t ever be 100% eliminated no matter what. It is my job as a nurse and person to think about what I am doing, question myself, question others, ask questions, make changes if necessary, and follow protocol. If something doesn’t feel right, I need to stop and think about it for a second. I also realize the value of the electronic health record and the fact that patient safety is perhaps the main focus of the entire system. It is convenient for us to be able to look at patient information at the click of a button but to be able to see that information to help in a critical situation or to plan care, that is so beneficial not only for healthcare professionals but for the patient and their overall safety, health, and progression.

3.  My feelings/experiences from the individual and team activities:

I enjoyed this week even though reading that case study was SO depressing. I’m glad I was able to discuss it with my class members and come a consensus as to why and how mandatory changes affect outcomes. It was good to realize that everyone felt that same way I did and we all have those similar fears as being new nurses. Nobody wants to make mistakes.
4. How I will utilize the information learned in my nursing practice:

      I can’t be afraid of mistakes. But I can minimize how many I make and what I do about it when a mistake is made. I will continue to always ask questions and utilize the resources I have. I also want to always listen to the patient and their family members. I have dealt with some helicopter children when it comes to care for their mother or father. Some nurses have been really irritated by that but I honestly am happy to answer questions over and over for them. I’m happy to listen to their concerns and talk to the doctor again about the same medication. I want to do anything and everything I can to prevent mistakes and errors by involving those people that know the patient the best.
5. My personal feelings about the material covered:

I though this week was full of beneficial information. Case studies always make an impact and I learn a lot from reading about these experiences of other people. I think it was important for me to realize that human error is a part of this practice but patient safety always needs to be the goal and I need to do everything I can to help honor and protect that.