QSEN Case Western Frances Payne Bolton School of Nursing

Quality and Safety Education for Nurses

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Patient Safety and Quality Improvement Educational Strategy for Pre-Licensure Students

Posted by on Mar 1, 2016 in News |

The educational strategy, a one four-hour learning activity, engages pre-licensure nursing students in the application of a QI tool and systems thinking approaches to patient safety. The non-graded patient safety and QI educational strategy encompasses a two-pronged approach. First Prong The first prong consists of an introduction to patient harm using a video (The Josie King Story, 2001). In small groups, students brainstorm patient safety risks to Josie’s safety by answering the following question. In what ways could or should the nurse have recognized risks to Josie’s safety? The first prong culminates with a “Patient Safety and QI. Educational Strategy” slide presentation, which includes two theory bursts. This slide presentation was adapted from Phase III of the QSEN National Initiative, Patient Safety and Quality Improvement Learning Module (2009). Second Prong The second prong introduces students to systems thinking and root cause analysis by using a fishbone diagram. This QI tool visually displays underlying causes for a specific problem or effect. The second prong encompasses a series of seven steps. In the first step, small groups of six to eight students, review a case study to examine the impact of a medication error from a systems perspective. Next, the faculty facilitator describes the purpose of a fishbone diagram and how to complete the diagram. There are a variety of videos available on the internet demonstrating how to complete a fishbone diagram. The faculty facilitator assigns each group one branch of a fishbone diagram—staff, work environment, admission process, and computer system. In the third step, ask each group to identify underlying causes for the medication error that resulted in deterioration of the patient’s medical condition as described in the case study. To ensure students stay on track in completing their assigned individual branch, the faculty facilitator guides individual groups to continually ask the question “why?” with the goal of thoroughly and accurately identify all underlying causal factors. In the fourth step, each student group generates one – two system improvement recommendations and any immediate corrective actions that address causal factors within the assigned individual branch. The fifth step occurs upon completion of the fishbone diagram. One student group exchanges a fishbone...

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Quality-Safety Project Poster

Posted by on Dec 8, 2015 in Teaching Strategies |

The Quality-Safety Project Poster is an activity designed to expose students to the following processes: 1) identifying a quality-safety problem in the clinical arena; 2) using quality tools to analyze issues; and 3) determining an action plan to address the issues/problems. Students collaborate with team members and present Quality-Safety posters to the entire School of Nursing faculty and student body at the end of each semester. Around the fourth week of the semester, students discuss the quality movement, adverse events and medical errors, the IOM Six Aims, and QSEN competencies in class. Then students form a team of three to work together on a quality-safety project during the remainder of the semester. Students are given 10-20 minutes at the beginning of each class to meet and discuss their projects. The faculty is available during this time and meets with each team to address any questions and provide guidance. Following is an overview of the strategy (see submitted materials for specific student guidelines): • In-class Preparation for the Project: Students view the Lewis Blackman story available at http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/ and review various quality improvement strategies that could be used to improve care such as root cause analysis and plan-do-study-act. In their teams, students work on a fishbone diagram related to the Lewis Blackman story. Teams compare and contrast their fishbone diagrams with other teams. • Students Identify a Clinical Problem/Issue for Team QI Project – students can select: o A clinical problem/issue identified during clinical practice. Examples include problems or issues related to staffing, patient safety, nurse safety, failure to meet practice standards, communication, etc…. o An adverse event or medical error identified during clinical practice. Examples include errors related to medication administration, standards of practice, procedures, near misses, etc…. • Each Team Completes a Fishbone Cause and Effect Diagram for the Specific Problem/Issue Identified • Teams Explore the Problem/Issue in Terms of National Quality and Safety Initiatives: Link the identified problem/issue to national quality or safety indicators from at least one of the following Organizations. Teams are encouraged to link to more than one: o The Joint Commission (TJC) o National Patient Safety Goals (NPSG) o National Quality Forum (NQF)...

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Giving and Receiving Constructive Feedback

Posted by on Oct 12, 2015 in News |

This is a narrated presentation.  Students may listen to it on-line, at home, or in the classroom with a faculty member.  The presentation can be loaded into Electronic Course Frameworks and assigned. If assigned as an out of class activity, faculty can have students blog or post in discussions about what they gained from the presentation.

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Medication Error Reporting Form

Posted by on May 5, 2015 in Teaching Strategies |

The Medication Error Reporting Form was created to help students link the process of medication math problems in the classroom with potential patient outcomes as a result of calculation errors. Entry-level student’s that have minimal exposure to the clinical setting often have a difficult time understanding how medication math errors on a quiz or exam in the classroom are directly related to clinical patient safety. As a result, many students may make the same errors repeatedly because they fail to understand the dangers that exist for the patient related to their error. Strategy Implementation: Students are given medication math questions on selected quizzes and exams in their corresponding nursing course. If a student calculates a medication math question incorrectly, the question is treated as a medication error incident with a simulated patient, Susie Smith. The student must complete a medication error reporting form. The medication error reporting form requires the student to calculate the safe and correct dose which is verified by the course instructor. The student is then required to investigate what the medication is commonly given for and what are the potential adverse effects that Susie Smith may experience as a result of their medication error. Students are asked to identify safety measures that may help to prevent similar medication errors from occurring again and the student must reflect on how the medication error reporting form has changed their view of medication calculations and medication administration to patients. In conclusion, the student must sign the medication error reporting form to take accountability for the error just as a registered professional nurse would be required to sign a hospital incident...

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Unfolding Case Study: Applying the QSEN Competencies to the Care of Patients with Parkinson’s Disease

Posted by on Mar 4, 2015 in News |

Students will be instructed to review information on Parkinson’s Disease prior to class by visiting the National Parkinson’s Disease website http://www.parkinson.org/parkinson-s-disease.aspx. This unfolding case study powerpoint presentation will be provided in class. Students will be encouraged to brainstorm to answer the questions as the case study unfolds. Theory bursts are woven throughout the case study.  The presentation includes links to Lee Siverman’s Voice Training (LSVT), which is a proven program to help patients with Parkinson’s Disease speak loudly and walk with a more stable gait.  Following the class session, the case study will be posted for the class to retrieve so that theory content is available to...

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