Fundamentals Class 1


Class 1

August 31 2015


This is an overview of the first class and is mainly concerned with the improvement of practice over time and what organizations do this.


There was a negative culture in nursing for a long time that created a shame, blame, and shame culture.

  • creates fear over not knowing
  • hard to learn
  • want to cover up mistakes


IOM is the institute of medicine – leader in evidence based practices and learning the new best practices without bias.

    • To Err is human – (1999): 44,000- 98,000 people die due to medical errors
      • Average is 71,000
      • Equivalent to three jumbo jet crashes every other day
      • conclusion – not from individual errors but from bad systems, and patterns
        • such as stocking full strength toxic drugs
        • not mandatory to use some safety equipment ie. gait belt
        • Goal is to reduce errors by 50% in 5 years


  • Crossing the quality Chasm (2000)


        • Safe,
        • Timely
        • Effective
        • Efficient
        • Equitable
        • patient-centered care
          • all healthcare related fields need to be educated in five competencies.
            • patient centered care, teamwork, EBP, quality improvement, informatics, safety.
            • from a recommendation from the IOM
  • Keeping patients safe (2000) – nurses are the best at this due to the time spent with the patient.
    • Nursing leadership, adequate staffing, safety, EBP
    • ongoing learning, colaboration, work design to promote safety, stress pt safety.


AHRQ: Agency for Healthcare Research and Quality


  • Best Practices are widely accepted and implemented over 17 years after the data is revealed.


The Joint Commission – work to improve systems through accreditation

    • tracks sentinel events nationally
      • unexpected death,physical or psychological injury, or risk thereof.
    • Required to report to the commission.


NQF – The National Quality Forum – Improve practices as well

  • they do not work together due to Money $


IHI Institute for healthcare Improvement – looks at world health

    • implementation of these interventions
      • RRT, AMI Care reliability, Med reconciliation, Surgical site infection bundle, ventilator bundle, Central venous line bundles.

5 million Lives campaign – avoid 5 million incidences of harm in 24 months.


NSO nursing centered outcomes


conclusion of to Err is Human study: not much has changed and though standardization and checklists it can still improve


Healthcare is a complex and adaptive system and therefore unpredictable


Swiss cheese model (cook 1997): all lines of defence have holes and mistakes can make it through.

  • sharp end is at the bedside (nurses)  
  • blunt end is the Manufacturer end or beginning

HRO – High Reliability Organizations

  • Preoccupation with failure
  • Reluctance to simplify interpretation
  • sensitivity to operations
  • commitment to resilience
  • deference to expertise


good nurses:

  • Anticipate
  • proactive monitoring
  • strategic delegation
  • Individualized paper memory aids
  • Stacking or prioritizing



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