After reading Chapter 8 and reviewing the lecture power point (located in lectures tab),  please answer the following questions.  Each question must have at least 3 paragraphs and you must use at 3 least references (APA) included in your post.
1.  Describe a clinical experience that was troubling to you.  Describe what bothered you about the experience and what could have you done differently utilizing critical thinking.
2.  Describe how patients, families, individual clinicians, health care teams, and systems can contribute to promoting safety and reducing errors.
3.  Describe factors that create a culture of safety.Chapter 8
Patient Safety and
Nursing Practice
Patient Safety
• Ensures that nursing practice is safe, effective,
efficient, equitable, timely, and patient-centered
• Minimization of risk of harm to patients and
providers through both system effectiveness and
individual performance (QSEN & NOF)
To Err is Human: Building a Safer
Health System (IOM, 2000)
• At least 44,000 and possibly up to 98,000
people die each year as the result of
preventable harm
• Cause of the errors is defective system
processes that either lead people to make
mistakes or fail to stop them from making a
mistake, not the recklessness of individual
• Error is the failure of a planned action to be
completed as intended, or the use of a wrong
plan to achieve an aim with the goal of
preventing, recognizing, and mitigating harm
• Common errors include drug events and
improper transfusions, surgical injuries and
wrong-site surgeries, suicides, restraint-related
injuries or death, falls, burns, pressure ulcers,
and mistaken patient identities (IOM, 2000)
Event Analysis
• Individual approach or system approach
– Culture of blame
– Culture of safety
– Just culture
• Root-cause analysis
• Reason’s Adverse Event Trajectory
Classification of Error
• Type of error
– Communication
– Patient management
– Clinical performance
• Where the error occurs
– Latent failure and active failure
– Organizational system failures and system process
or technical failure
Human Factor Errors
• Skill-based
– Deviation in the pattern of a routine activity such
as an interruption
• Knowledge-based
• Rule-based
– Conscious decision by the nurse to “workaround”
or take a shortcut, so the system defense
mechanisms are bypassed, thereby increasing risk
of harm to patient
To Err is Human: Building A Safer
Health System (IOM, 2000) (1 of 2)
• User-centered designs with functions that make
it hard or impossible to do the wrong thing
• Avoidance of reliance on memory by
standardizing and simplifying procedures
• Attending to work safety by addressing work
hours, workloads, and staffing ratios
• Avoidance of reliance on vigilance by using
alarms and checklists
To Err is Human: Building A Safer
Health System (IOM, 2000) (2 of 2)
• Training programs for interprofessional teams
• Involving patients in their care; anticipation of
the unexpected during organizational changes
• Design for recovery from errors
• Improvement of access to accurate, timely
information such as the use of decision-making
tools at the point of care
Crossing the Quality Chasm: A New
Health System for the 21st Century
(IOM, 2000)
– Safe
– Timely
– Effective
– Efficient
– Equitable
– Patient-centered
• 10 rules for redesign
– Rule #6: Safety is a
system property
Keeping Patients Safe: Transforming the
Work Environment of Nurses
(IOM, 2004)
• Chief nursing executive should have leadership role
in the organization
• Creation of satisfying work environments for nurses
• Evidence-based nurse staffing and scheduling to
control fatigue
• Giving nurses a voice in patient care delivery
• Designing work environments and cultures that
promote patient safety
Preventing Medication Errors: Quality
Chasm Series (IOM, 2006)
• Paradigm shift in the patient-provider
• Using information technology to reduce
medication errors
• Improving medication labeling and packaging
• Policy changes to encourage the adoption of
practices that will reduce medication errors
Joint Commission National
Patient Safety Goals
• Reviewed and updated annually, focuses on
system-wide solutions to problems
• 2015 goals: Identify patients correctly, use
medications safely, improve staff
communication, use alarms safely, prevent
infection, identify patient safety risks, and
prevent mistakes in surgery
National Quality Forum Goals
• Improve quality health care by setting
national goals for performance improvement
• Endorsement of national consensus standards
for measuring and public reporting on
• Promoting the attainment of national goals
National Quality Forum Safe Practices
• Endorsed safe practices defined to be
universally applied in all clinical settings in
order to reduce the risk of error and harm for
• 34 practices have been shown to decrease the
occurrence of adverse health events
• Also endorses list of 29 preventable, serious
adverse events for public reporting
Sentinel Events
• An unexpected occurrence involving death or
serious physical or psychological injury or the
risk thereof
• Examples include wrong patient events, wrong
site events, wrong procedures, delays in
treatment, operative or postoperative
complications, retention of foreign body,
suicides, medication errors, perinatal death or
injury, and criminal events
• Healthcare organizations have responded to
incentive programs, accreditation standards, and
public opinion
• Professional organizations have responded with
revisions to standards that place more emphasis
on healthcare quality and patient safety
• Educators have responded by infusing quality
and safety concepts into student didactic and
clinical experiences guided by initiatives such as
the QSEN and Nurse of the Future
Patient Narratives
• A short video sharing the story of Josie King is
available at:
• A short video about The Betsy Lehman Center for
Patient Safety and Medical Error Reduction is
available at:
• The Chasing Zero: Winning the War on Healthcare
Harm video is available at:

• The Transparent Health−Lewis Blackman Story
video is available at:
Why Is Critical Thinking Important in
Nursing Practice?
• Essential to providing safe, competent, and
skillful nursing care
• The inability of a nurse to set priorities and
work safely, effectively, and efficiently may
delay patient treatment in a critical situation and
result in serious life-threatening consequences
Thinking Like a Nurse
• Clinical judgment
• Clinical reasoning
• Mindfulness
Clinical Judgment (1 of 2)
• Clinical judgments are more influenced by
what nurses bring to the situation than the
objective data about the situation at hand
• Sound clinical judgment rests to some degree
on knowing the patient and his or her typical
pattern of responses, as well as engagement
with the patient and his or her concerns
Clinical Judgment (2 of 2)
• Clinical judgments are influenced by the
context in which the situation occurs and the
culture of the nursing unit
• Nurses use a variety of reasoning patterns
alone or in combination
• Reflection on practice is often triggered by a
breakdown in clinical judgment and is critical
for the development of clinical knowledge and
improvement in clinical reasoning
Critical Thinking and Clinical
Judgment in Nursing
• Purposeful, informed, outcome-focused thinking
• Carefully identifies key problems, issues, and risks
• Based on principles of the nursing process, problem
solving, and the scientific method
• Applies logic, intuition, and creativity
• Driven by patient, family, and community needs
• Calls for strategies that make the most of human
• Requires constant reevaluating
Characteristics of Critical Thinking
• Rational and reasonable
• Involves conceptualization
• Requires reflection
• Includes cognitive skills and attitudes
• Involves creative thinking
• Requires knowledge
Characteristics of a Critical Thinker (1 of 2)
• Flexible
• Bases judgments on facts and reasoning
• Doesn’t oversimplify
• Examines available evidence before drawing
• Thinks for themselves
• Remains open to the need for adjustment and
adaptation throughout the inquiry
Characteristics of a Critical Thinker (2 of 2)
• Accepts change
• Empathizes
• Welcomes different views and values
examining issues from every angle
• Knows that it is important to explore and
understand positions with which they disagree
• Discovers and applies meaning to what they
see, hear, and read
Approaches to Developing Critical
Thinking Skills
• Nursing process
• Concept mapping
• Journaling
• Group discussions
Nursing Process
• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation
Concept Mapping
• Visual representation of the relationships
among concepts and ideas
• Useful for summarizing information,
consolidating information from different
sources, thinking through complex problems,
and presenting information in a format that
shows an overall structure of the subject
• Allows you to view your own thinking,
reasoning, and actions
• Helps create and clarify meaning and new
understandings of experiences
• Should be able to recall what you did or would
do differently and reasoning when you
encounter a similar situation
Journaling Suggestions
• What happened?
• What was the setting?
• What are the facts?
• What were the
important elements of
the event?
• What feelings and
senses surrounded the
• What did I do?
• How and what did I
feel about what I did?
• What preceded the
event, and what
followed it?
• What should I be aware
of if the event recurs?
Group Discussions
• Cooperative learning occurs when groups
work together to maximize learning
• Explore alternatives
– Different scenarios of “What if?”, “What else?”,
and “What then?”
• Arrive at conclusions
– Connect clinical events or decisions with
information obtained in the classroom

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