Kelly Vana's Nursing Leadership and Management

5 https://nursingworld.org to see nursing's position on culture of safety and just culture, Accessed August 28, 2019.

Go to the website for the Centers for Medicare and Medicaid Hospital Compare, www.medicare.gov/hospitalcompare/search.html. Accessed August 28, 2019. Enter several hospitals located close to your zip code. Review the ratings. What are their strengths? Where do they have opportunities to improve their safety?

What do you see in practice that is different from what you read in this chapter? Why do you think these differences exist?

How does the information from this chapter influence you as a nursing student?

How do you think you will use this chapter's information to change practice as a nurse?

How much or how little do you think this chapter's information will matter to you as a nurse leader?

1 Academy of Medical‐Surgical Nurses. (2019). Nurse resiliency. Retrieved from www.amsn.org/practice-resources/healthy-practice-environment/nurse-resiliency

2 Agency for Healthcare Research and Quality. (2013a). Agency for Healthcare Research and Quality (AHRQ). www.ahrq.gov

3 Agency for Healthcare Research and Quality. (2013b). TeamSTEPPS pocket guide. Retrieved from www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.pdf

4 Agency for Healthcare Research and Quality. (2017). Surveys on patient safety cultureTM. Retrieved from www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html

5 Agency for Healthcare Research and Quality. (2018a). Patient Safety Network. Root cause analysis. Retrieved from https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis

6 Agency for Healthcare Research and Quality. (2018b). Patient Safety Network: High reliability. Retrieved from https://psnet.ahrq.gov/primers/primer/31/high-reliability

7 Agency for Healthcare Research and Quality. (n.d.). Patient safety organization (PSO) program: Federally‐listed PSOs. Retrieved from www.pso.ahrq.gov/listed

8 American Association of Critical Care Nurses. (2014). ICU nurses benefit from resilience training. Retrieved from www.aacn.org/newsroom/ajcc-resilience-research

9 American Association of periOperative Nurses. (2018). AORN: Safe surgery together. Retrieved from www.aorn.org

10 American College of Healthcare Executives and Institute for Healthcare Improvement. (2017). Leading a Culture of Safety: A Blueprint for Success. Retrieved from https://www.osha.gov/shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf

11 American Nurses Association. (2010). Position statement: Just culture. Retrieved from https://nursingworld.org/psjustculture

12 American Nurses Association. (2016). Culture of Safety. Retrieved from www.nursingworld.org/practice-policy/work-environment/health-safety/culture-of-safety

13 American Nurses Credentialing Center (ANCC). (2017). 2019 magnet application manual. Silver Springs, MD: American Nurses Credentialing Center.

14 CDC. (2019, June 26). Promotional materials: clean hands count. Retrieved from www.cdc.gov/handhygiene/campaign/promotional.html

15 CDC. (2019). Centers for Disease Control and Prevention. Retrieved from www.cdc.gov

16 Centers for Disease Control and Prevention (CDC). (2019). Hand hygiene in health care settings. Retrieved from www.cdc.gov/handhygiene

17 Centers for Medicare and Medicaid Services. (2018a). Hospital‐acquired condition reduction program (HACRP). Retrieved from www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/HAC-Reduction-Program.html

18 Centers for Medicare and Medicaid Services. (2018b). The hospital value‐based purchasing (VBP) program. Retrieved from www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing.html

19 Centers for Medicare and Medicaid Services. (2018c). Readmissions Reduction Program (HRRP). Retrieved from www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

20 Centers for Medicare and Medicaid Services. (2018d). What are the value‐based programs? Retrieved from www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs.html

21 Chassin, M. R., & Loeb, J. M. (2013). High‐reliability health care: Getting there from here. The Milbank Quarterly, 91(3), 459–490.

22 Classen, D. C., Lloyd, R. C., Provost, L., Griffin, F. A., & Resar, R. (2008). Development and evaluation of the Institute for Health care improvement global trigger tool. Journal of Patient Safety, 4(3), 169–177.

23 Cook, R., & Woods, D. (1994). Operating at the sharp end: The complexity of human error. In M. S. Bogner (Ed.), Human error in medicine (pp. 255–310). Hillsdale, NJ: Erlbaum and Associates.

24 DNV. (2018). Hospital Accreditation. Retrieved from http://dnvglhealth http://care.com/accreditations/hospital-accreditation

25 Drucker, P. F. (1974). Management: Tasks, responsibilities, practices. New York: Harper & Row.

26 FDA. (2018). MedSun: Medical Product Safety Network. Retrieved from www.fda.gov/MedicalDevices/Safety/MedSunMedicalProductSafetyNetwork/default.htm

27 Gerdik, C., Vallish, R. O., Miles, K., Godwin, S. A., Wludyka, P. S., & Panni, M. K. (2010). Successful implementation of a family and patient activated rapid response team in an adult level 1 trauma center. Resuscitation, 81(12), 1676–1681.

28 Health and Human Services Office of Inspector General. (2012). Hospital incident reporting systems do not capture most patient harm. Retrieved from https://oig.hhs.gov/oei/reports/oei-06-09-00091.asp

29 Healthcare Facilities Accreditation Program. (2017). About HFAP. Retrieved from www.hfap.org/about-hfap/

30 Helmreich, R. L., Merritt, A. C., & Wilhelm, J. A. (1999). The evolution of crew resource management training in commercial aviation. The International Journal of Aviation Psychology, 9(1), 19–32.

31 Hughes, R. G. Tools and Strategies for Quality Improvement and Patient Safety. In R. G. Hughes (Ed.), Patient Safety and Quality: An Evidence‐Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 44. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2682/

32 Institute for Healthcare Improvement. (2018). IHI global trigger tool for measuring adverse events. Retrieved from www.ihi.org/Topics/TriggerTools/Pages/default.aspx

33 Institute for Safe Medication Practices. (2018). Institute for Safe Medication Practices. Retrieved from www.ismp.org/about/default.aspx

34 Institute of Medicine. (1999). To err is human. Washington, DC: National Academy of Sciences.

35 Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academy of Sciences.

36 Institute of Nuclear Power Operations. (November 2004). Principles for a Strong Nuclear Safety Culture. Retrieved from www.emcbc.doe.gov/Content/Office/inpo_principles_for_a_strong_nuclear_safety_culture.pdf

37 Jeffs, L., Baker, G. R., Taggar, R., Hubley, P., Richards, J., Merkley, J., Shearer, J., Webster, H., Dizon, M. & Fong, J. H. (2018). Attributes and actions required to advance quality and safety in hospitals: Insights from nurse executives. Nursing Leadership, 31(2), 20–31. doi:10.12927/cjnl.2018.25606

38 Kreiser, S. (2012). High reliability health care: Applying CRM to high‐performing teams, Part 5. PSQH – Patient Safety and Quality Health care. Retrieved from www.psqh.com/news/high-reliability-health care‐applying‐crm‐to‐high‐performing‐teams‐part‐5.

39 Makary, M. A., & Daniel, M. (2016). Medical error – The third leading cause of death in the U.S. BMJ, 353, i2139.