Quality Improvement In Health Care

And Patient Safety.

DATA

Data plural of datum, which is originally latin noun meaning some Thing given. It means fact or piece of
Information, It's a collection of information gatthered by observation measurement, research or
analysis it may consist Facts numbers, names or even discription of things, It can also be organized in the
formed of graphs , charts or table . Eg if we decided to find out the tallest or shortest student in our
class room, we do find out by recording the height and weight of every student and tabulate it.This
table can be used to obtained information about individual student regarding to their height and weight
and it can also be use for the purposes of calcution of height and weight of Every student in This class.
And as mentioned above. Thereby finding out the tallest and shortest in this classroom.

Data also help us (scientist) to know the wheather forecast that normally report in our news channels.
the least of minimum temperature., maximum tempreture rainful prediction and measurement.While in
nursing, treatment of our patients through data obtained during ward observation, physical head to the
Exam, laboratory Investigation and history taking which tell us more about patient.In all the research
work we do, It help us to give suggestion and solution for Improvement of our daily living through the
data we obtained by distribution of questionners and data we obtained from record and sentistic
depertment.

CLASSIFICATION OF DATA

.Data can be classified Into two Qualitative dataQuantitative data

1. Qualitative data.* it describe the quality of something or someone. It's descriptive information e.g the
phone with 4G network and the phone with 5G network ( description about something ) then skin
colours, eyes ,ears , skin texture etc. ( description about someone), it gives qualitative information about
someone or something

2. Quantitative data It provides numerical information e.g the height of individual e.g 6 feet tall and
weight of individual e.g 75kg.

GETTING MORE FROM DATA

The data a nurse collect from patient tells him/her the type of patient they dealing with, what they like
and most importantly how to manage their patient effectively. To help you to get data there, there are
11 tips that guide the nurse.

1. know your key performance indicators (KPIs) :Collecting data is your first step but a nurse need to
identify his/her KPIs . what your data indicate you to do will tell whether you are doing well or making
mistake by close monitoring of your patient and consultation from senior nurse in charge.
2. organised your data in order of importance: your data should be organized in order of what your
patient need urgently to save his life or alleviate his suffering, by doing that it takes you closely to the
area of improvement and achieve your goals as plan.

3. Know what action you supposed to take : it make a nurse to decide whether action should be take
based on the data at hand or not. If the nurse feels unsure invite co-nurse in decision making before
implementation.

4.Introduced structure and automation wherever possible: make sure that their is structure around on
how to processed your data or secondly using automation.

5. Set storage up in the cloud and store it all : Data is highly valuable and can be used/liberage to
improve patient care, therefore if you can be able to generate data and believe is important even in
future reference of patient care it is imperative to set up and store in the cloud.

6. Respect data privacy : respecting data privacy need to be a thing of importance, it's unethical to
disclose your patient data to anyone who is not part of your patient care doing that quickly erode trust
and undermine nurse-patient relationship.

7. Don't be afraid of big data : Big data leads to meaningful result but it needs to be broken down for
easy management.

8. Decide what elements matters : you need to understand which procedure to be carried out based on
data at hand and which one should come early or later in the circle of management, if a nurse discoverd
that there should be a change in the procedure she/he decides you can uncovered actionable insight in
timely manner.

9. Building a data driven culture : It's important to get your colleagues advice and interest in the data
you intend to use, not just you alone there are somethings that we advocate (nurses) such as helping
each other, in the process of management that help us to have collective decision.

10. Avoid assumption : Don't fall in to the trap of making assumption and looking for evidence, it's easy
to find justification for your biases by taking a true science approach.

11. Don't collect but Intergrate : The most important thing is not about taking data but Intergrate the
data, and analytics in to work flow, this have nurses through their monitoring tools and automation that
can quickly respond to and impact Management in a will time.

JIGAWA STATE STATE COLLEGE OF NURSING SCIENCES HADEJIA

PRESENTATION

GROUP ONE(1)

QUALITY IMPROVEMENT AND PATIENT CARE AND SAFETY

TUTOR: MAL SULAIMAN MUHAMMAD KANTOMA

QUESTIONS: WRITE ON;

1 –SCIENCE OF IMPROVEMENT

2 –SYSTEM OF PROPOUND KNOWLEDGE

3-- UNDERSTANDING VARIATION

4-- PSYCHOLOGY OF CHANGE

GROUP MEMBERS

S/N

NAMES

1.AISHA SHUAIBU

2.ISMAIL ABBAS

3.UMAR HARUNA HAMZA

4.AHMADU ABUBAKAR

5.FATIMA KABIR MUHAMMAD

6.UMMI SAIDU

7.ZAINAB ABDULLAHI SARO

8.UMMU-KHADIJA SULAIMAN

9.USMAN ISAH MUHAMMAD

10.ADAMA SANI UMAR

11.MUHAMMAD ABUBAKAR SADIQ

12.HAUWA HASSAN SULAIMAN

MAY, 2024

1 -- Science Of Improvement

The science of improvement is an applied science that includes:

The interaction of systems thinking, understanding variation, the theory of knowledge, and the
psychology of change that are applied to improve the performance of processes, products, systems,
services, organizations, and communities. Improvement science is a problem-solving approach centered
on continuous inquiry and learning.

The proper application of this science requires integration of a set of improvement methods and
tools with knowledge of subject matter to develop, test, implement, spread, and scale up changes that
lead to improvement.

A core principle of improvement science is that a system’s performance is a result of its design and
operation, not simply a result of individuals’ efforts within the system. Building from this foundation,
improvement science helps organizations build a shared understanding about how their systems work,
where breakdowns occur, and what actions can be taken to improve overall performance.

One of the primary tools of improvement science is the Plan-Do-Study-Act (PDSA) inquiry cycle. This
cycle serves as a basic learning tool through which practitioners test changes, document the results, and
revise their theories about how to achieve their a

2--SYSTEM OF PROPOUND KNOWLEDGE

William Deming was an American statistician, professor, lecturer, and consultant who defined a theory
of management and leadership called the System of Profound Knowledge.

It is a theory that provides a framework of thought and action for any leader wishing to transform or
improve their team or organization and consists of four components, or ‘lenses’ through which to view
the world simultaneously.

Improving systems is about appropriately applying the four principles and practices so that the
organization can simultaneously reduce costs through reducing waste and variation whilst increasing
quality.

There are three components of propound knowledge:

1-An appreciation of a system

Deming defined a system as ‘a network of interdependent components that work together to try to
accomplish the aim of the system. The aim for any system should be that everybody gains, not one part
of the system at the expense of any other’.

2-Understanding of variation

Understanding variation is critical to managing systems effectively.

3-Psychology

Leaders can create the best system, know all about variation and knowledge, and still not have a
successful organization if they don’t understand people, and particularly what motivates them to want
to do a good job. Deming understood the importance of effective people management and accepted
that people cannot all be managed in the same way. He also understood that people are primarily
motivated by intrinsic needs, including taking pride in workmanship and working with others to achieve
common goals, in contrast to simply being motivated by monetary reward.

UNDERSTANDING VARIATION

"In improvement, it is critical to understand that every process has inherent variation that we want to
understand."

Health care organizations at all different levels, from local and regional to national, use data to
understand their performance — though they do not always do so effectively.

Types of understanding variation

Intended variation is an important part of effective, patient-centered health care. It is also called
purposeful, planned, guided or considered variation.

Example: A physician purposely prescribes different doses of a drug to a child and an adult.

Unintended variation is due to changes introduced in to health care process that are not purposeful,
planned or guided. They usually create inefficiencies, waste, ineffective care, errors and injuries in our
health care system and reducing them usually results in improved outcomes and lower costs.

: Without realizing it, a physician prescribes pain medication to one person and does not prescribe it to a
second person with the same condition due to implicit bias (subconscious stereotyping) about who
needs pain relief.

4 --PSHYCOLOGY OF CHANGE

Change is a complex process, especially within the context of quality improvement initiatives. In the field
of psychology, there are several theories and frameworks that can help us understand how individuals
and organizations perceive, process, and adapt to change. Here are a few key concepts related to the
psychology of change under quality improvement:

1. Kotter's 8-Step Change Model: Developed by Harvard professor John Kotter, this model outlines a
series of steps for leading organizational change. It emphasizes the importance of creating a sense of
urgency, building a guiding coalition, and empowering employees to act on the change vision.

2. ADKAR Model: This model focuses on individual change management and stands for Awareness,
Desire, Knowledge, Ability, and Reinforcement. It highlights the importance of addressing the emotional
and psychological aspects of change for individuals to successfully transition.
3. Social Cognitive Theory: This theory posits that people learn by observing others and the outcomes of
their actions. In the context of quality improvement, this theory suggests that role modeling, social
support, and positive reinforcement can facilitate behavioral change.

4. Systems Theory: This theory views organizations as complex systems where change in one part can
impact the entire system. Understanding how different components of the system interact and
influence each other can be crucial for implementing effective quality improvement initiatives.

5. Psychological Resilience: Change can be stressful and challenging, and individuals and organizations
need to be resilient in the face of uncertainty and setbacks. Developing coping strategies, fostering a
positive mindset, and cultivating a culture of adaptability can help build resilience during times of
change.

Incorporating these psychological principles into quality improvement efforts can help leaders and
change agents navigate the complexities of change, foster buy-in and commitment from stakeholders,
and ultimately drive sustainable improvements in quality and performance.

SCHOOL AND NURSING SCIENCE

HADEJIA CAMPUS

GROUP TWO(2)

COURSE: QUALITY IMPROVEMENT IN PATIENT CARE AND IN PATIENT SAFETY

TITLE: GROUP PRESENTATION

COURSE TUTOR: MAL. SULAIMAN M. KANTOMA

GROUP MEMBERS:

1. AMINU MAGAJI

2. KABIRU SA'IDU

3. ISAH TIJJANI

4. AISHA MUHAMMAD SABIU

5. MAIMUNAT MUHAMMAD ISAH

6. RUKAYYA ABDULMAJID

7. SAFIYYA IBRAHIM WAKILI

8. MUSA MUHAMMAD BASHIR

9. HAUWA IBRAHIM MAKAMA

10. UMMISALMA IBRAHIM

ANSWER

1. APPRECIATION OF SYSTEM

Appreciation of System refers to the understanding and recognition of the interconnectedness and
interdependence of various components within a healthcare system. It involves acknowledging the
complex relationships between different elements and how they impact patient care.

Example: A nurse recognizes that a delay in laboratory test results (one component) can affect the
timely administration of medication and ultimately impact patient outcomes (another component).

2. THEORY OF KNOWLEDGE

Theory of Knowledge (ToK) refers to the philosophical perspective on the nature of knowledge and how
it is acquired, validated, and used in nursing practice. It explores the relationship between the nurse, the
patient, and nursing knowledge.

Example: A nurse's ToK might emphasize evidence-based practice, critical thinking, and empathy,
guiding their approach to patient assessment and care planning.

3. MODELS OF IMPROVEMENT

Models of Improvement are structured approaches to enhance the quality and safety of nursing care.
They provide a framework for identifying problems, analyzing root causes, and implementing solutions.

Examples:

- Root Cause Analysis (RCA) to investigate adverse events

- Failure Mode and Effects Analysis (FMEA) to proactively identify potential failures

- Plan-Do-Check-Act (PDCA) cycle to implement and evaluate quality improvement initiatives

4. BUILDING QUALITY IMPROVEMENT

Building Quality Improvement involves creating a culture and infrastructure that supports continuous
improvement and learning in nursing practice. It requires leadership commitment, nurse engagement,
and a systematic approach to quality.

Example: A hospital's nursing department establishes a quality improvement team, provides training
and resources, and encourages nurses to identify and address quality issues, such as fall prevention or
pressure ulcer reduction.

JIGAWA STATE COLLEGE OF NURSING SCIENCES

HADEJIA CAMPUS

SET FIVE (5) STUDENT NURSES

TITTLE: GROUP PRESENTATION

COURSE: QUALITY IMPROVEMENT IN HEALTH CARE AND PATIENT SAFETY

GROUP THREE (3)

TOPICS:

1. IMPROVEMENT PLAN AND TEST OF CHANGE.

> Formalizing your improvement plan. > Developing an aim

> Measuring for improvement. > Establishing a family of measure

> Idea for change

2. LEARNING FROM TEST OF CHANGE.

> An overview of plan-do-study-act. > Inter-rative test of change

GROUP MEMBERS

1. ABDULLAHI MUHAMMAD ABUBAKAR

6.ZAHARA'U ALIYU YUSUF

2.ABDURRAHMAN A. MUSA
7. IBRAHIM HASSAN

3.ABDURRAHMAN MUHAMMAD

8.NABILA KABIR ABDULLAHI

4.AISHA HUSSAINI IBRAHIM

9.MUHAMMAD AMINU YUSIF

5.HAUWA'U IBRAHIM ADAM

COURSE TUTOR:. MAL. SULAIMAN M. KANTOMA.

MAY, 2024.

1. IMPROVEMENT PLAN AND TEST OF CHANGE.

1.1. FORMALIZING YOUR IMPROVEMENT PLAN

Formalizing an improvement plan in quality improvement for patient care involves:

1. Define the problem: Clearly articulate the issue or opportunity for improvement.

2. Establish a specific aim: Define a measurable and achievable goal.

3. Conduct a root cause analysis: Identify underlying causes and contributing factors.

4. Develop a detailed plan:

- Define interventions and strategies.

- Identify responsible team members and roles.

- Establish timelines and milestones.

- Determine resources and budget.

- Develop evaluation metrics and monitoring plans.

5. Write a formal improvement plan document: Include the above elements and:

- Introduction and background

1.2. Developing an aim

Developing an aim in quality improvement for patient care involves several steps:

1. Define the problem: Identify a specific issue or area for improvement in patient care, such as reducing
hospital-acquired infections or improving patient satisfaction.
2. Establish a clear aim: Write a concise and measurable statement that defines the desired outcome,
such as "Reduce hospital-acquired infections by 20% within the next 6 months" or "Improve patient
satisfaction ratings by 15% within the next 3 months."

3. Specify the population: Identify the specific patient population affected by the problem, such as
pediatric patients or patients with diabetes.

4. Set SMART goals: Ensure the aim is Specific, Measurable, Achievable, Relevant, and Time-bound
(SMART).

5. Conduct a root cause analysis: Identify the underlying causes of the problem to address the
underlying issues.

6. Develop a plan: Outline the interventions and strategies to achieve the aim, such as implementing
new protocols, training staff, or improving communication.

7. Establish metrics and monitoring: Define the metrics to track progress and monitor regularly to adjust
the

1.3. Measuring for improvement

Measures for improvement in patient care include:

1.Clinical outcomes: Mortality rates, readmission rates, complication rates, and patient satisfaction
scores.

2. Quality metrics: Core measures (e.g., blood pressure control, vaccination rates), HEDIS (Healthcare
Effectiveness Data and Information Set) measures, and National Quality Forum (NQF) endorsed
measures.

3. Patient experience: Press Ganey or HCAHPS (Hospital Consumer Assessment of Healthcare Providers
and Systems) scores, patient satisfaction surveys, and net promoter scores.

4. Safety metrics: Fall rates, hospital-acquired infection rates, and medication error rates.

5. Efficiency and productivity: Length of stay, emergency department throughput, and staff productivity
metrics.

6. Patient engagement and empowerment: Patient activation measures, patient engagement scores,
and patient-reported outcomes.

7. Care coordination and transitions: Readmission rates, discharge instructions compliance, and care
transition quality metrics.

8. Financial performance: Cost per case, revenue cycle metrics, and return on investment (ROI) analysis.
These measures help healthcare organizations identify areas for improvement, track progress, and
evaluate the effectiveness of quality improvement initiatives.

1.4. Establishing a family of measure

FAMILY OF MEASURE.

In quality improvement work, three (3) types of measures are used to measure and understand
improvement:

1. Outcome Measures 2. Balancing Measures 3.Process Measures

Collectively, these measures are known as the 'Family of Measures’.

Measurementis an essential element of testing and implementing changes.

1. OUTCOME MEASURES.

Start with your outcome measure. This is directly linked to your aim statementand helps to determine
how the system is performing i.e.,the end result. This is often the voice of the patient.

3. PROCESS MEASURES

Then identify your process measures. These measures reflect the parts of the system that you are
changing that will influence your overall improvement project aim. This helps you to understand if the
changes are having a positive or negative impact on your project.You are assessing if the parts the
system are performing as planned.

2. BALANCING MEASURES.

Finally, your balancing measure will support you to determine how the changes are impacting on the
wider system.They are defined at the beginning of your project and are measured and reviewed
throughout. When looking at Balancing Measures it’s important to consider if they are impacting your
project or if they are being impacted throughout your project.

1.5. Idea for change.

Ideas for change in quality improvement for patient care include:

1. Implementing evidence-based practices: Adopting proven guidelines and protocols to improve patient
outcomes.

2. Improving communication: Enhancing patient-provider communication, care transitions, and team

collaboration.

3. Enhancing patient engagement: Empowering patients through education, shared decision-making,

and patient-centered care.
4. Streamlining processes: Reducing unnecessary steps, improving workflow efficiency, and minimizing
waste.

5. Leveraging technology: Utilizing electronic health records, telemedicine, and data analytics to improve
care.

6. Fostering a culture of safety: Encouraging transparency, reporting, and learning from errors.

7. Improving staff education and training: Enhancing skills and knowledge to provide high-quality care.

8. Addressing social determinants of health: Considering patients' social and environmental factors to
provide more comprehensive care.

9. Conducting regular quality improvement projects: Continuously identifying and addressing areas for
improvement.

10. Enhancing patient flow and throughput: Optimizing patient movement and reducing wait times.

11. Reducing readmissions: Implementing transitional care programs and follow-up appointments.

12. Improving patient satisfaction: Addressing comfort, amenities, and overall patient experience.

2.0 LEARNING FROM TEST OF CHANGE.

2.1. AN OVERVIEW OF PLAN-DO-STUDY-ACT

The Plan-Do-Study-Act (PDSA) method is a way to test a change that is implemented. Going through the
prescribed four steps guides the thinking process into breaking down the task into steps and then
evaluating the outcome, improving on it, and testing again.

The Plan-Do-Study-Act Cycle (or PDSA) is a useful tool to test changes. The method is based on a ‘trial
and learning’ approach to improvement. The cycle consists of smallscale tests of planned interventions
and changes (P & D), followed by assessment and improvement of the initial plan (S & A). If many
changes are planned, each one of them can be tested concurrently or consecutively with a PDSA cycle.
The team learns from each test what worked, what did not work, why, and what changes/interventions
should be kept, modified, or discarded. The team continues testing through PDSA cycles until an
intervention is identified as suitable for broader implementation.

The Phases of the Plan-Do-Study-Act Cycle

• P=Plan to test selected change.

In this phase the team prepares a detailed plan including who will be involved in testing, what actions
will be done, when the actions will start and how the changes will be evaluated.

• D=Do the test (i.e. carry out the plan) and collect data for analysis.
As the change is being implemented, data collection may be as simple as counting observations and
recording them on a tally sheet. It is essential to document problems and unexpected observations as
these will help in understanding why a change did or did not result in improvement.

• S=Study the results.

Compare data to predictions. Has the test resulted in an improvement? Can this be implemented on a
larger scale? Analysis of the data will help identify reasons why the change did not produce the expected
improvement and the exact magnitude of the impact of the change on the improvement objective.

• A=Act on the results.

Decide, based on results, whether to implement/replicate the changes or to select another possible
change to test. Action should be rationally based on what was learnt from testing the planned
intervention.

2.2. INTER-RATIVE TEST OF CHANGE.

The inter-rative test of change is a key component of the Model for Improvement, a widely used quality
improvement framework. It enables organizations to quickly and effectively test and implement
changes, leading to improved patient care and outcomes.

An inter-rative test of change is a quality improvement methodology that involves:

1. Plan: Identify a problem, define an aim, and develop a plan for improvement.

2. Do: Implement the plan on a small scale, typically with a single team or unit.

3. Study: Collect data and evaluate the effectiveness of the change.

4. Act: Refine the change based on the results and lessons learned.

5. Repeat: Cycle through the process again, gradually scaling up the change to other teams or units.

This iterative approach allows for:

- Rapid testing and refinement of ideas

- Identification and mitigation of unintended consequences

- Building of momentum and engagement among stakeholders

- Continuous learning and improvement.

JIGAWA STATE COLLEGE OF NURSING SCIENCE,

HADEJIA CAMPUS.
 SET FIVE STUDENT NURSES

GROUP:04

COURSE: QUALITY IMPROVEMENT IN HEALTH CARE AND PATIENT SAFETY

TITTLE: GROUP PRESENTATION

TOPICs:

1.definition of patient safety and adverse event

2.Culture of safety

3.Building safer and more reliable system

4.definition of error and harm

COURSE TUTOR: MALAM SULAIMAN M. KANTOMA

MAY,2024.

GROUP MEMBERS
1.AISHA AHMAD GARBA

2.MuKTAR ADAMU

3.MAIMUNATU UMAR MUHAMMAD

4.MUHAMMAD UMAR MUHAMMAD

5.AISHA MUHAMMAD ADAM

6.HASSANA YUSHA'U

7.SALIHU SHEHU SULE

8.NAIMA YAU DAHIRU

9.ASMA'U IDRIS YAU

1.

INTRODUCTION

“First, do no harm” is the most fundamental principle of any health care service. No one should be
harmed in health care; however, there is compelling evidence of a huge burden of avoidable patient
harm globally across the developed and developing health care systems. This has major human, moral,
ethical and financial implications.
 PATIENT SAFETY is defined as “the absence of preventable harm to a patient and reduction of risk
of unnecessary harm associated with health care to an acceptable minimum."Patient safety is a
discipline that emphasizes safety in health care through the prevention, reduction, reporting and
analysis of error and other types of unnecessary harm that often lead to adverse patient events

Within the broader health system context, it is “a framework of organized activities that creates
cultures, processes, procedures, behaviours, technologies and environments in health care that
consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely
and reduce impact of harm when it does occur."

WHILE

An Adverse even( AE) is a harmful and negative outcome that happens when a patient has been
provided with medical care.Medical treatment may include a procedure, surgery, or medication

An adverse event can be defined as any unintended injury or complication that occurs during
healthcare delivery. Adverse events can range from minor, such as an allergic reaction to a medication,
to severe, such as death or permanent disability. They can be caused by a wide range of factors,
including human error, system failures, or patient-related factors, and they can occur at any point in the
healthcare delivery process.

2.CULTURE OF SAFETY:The American Nurses Association describes a culture of safety as one that
includes openness and mutual respect when discussing safety concerns and solutions without shifting to
individual blame, a learning environment with transparency and accountability, and reliable teams.

Culture of safety is a set of values, beliefs, and attitudes shared by all members of a healthcare
organization that prioritize patient safety above all else. It emphasizes the importance of creating an
environment where everyone feels empowered to identify and report safety concerns without fear of
retaliation. This includes healthcare workers at all levels of the organization, A culture of safety
encourages transparency, learning from errors, and implementing systems to prevent future mistakes.

SAFETY THEMES IN CULTURE OF SAFETY

Safe culture: Creating and maintaining a strong patient safety culture, with patient safety and error
reduction embraced as shared organizational values.

Safe care: Ensuring that the actual and potential hazards associated with high-risk procedures,
processes, and patient care populations are identified, assessed, and managed in a way that
demonstrates continuous improvement and ultimately ensures that patients are free from accidental
injury or illness.

Safe staff: Ensuring that staff possess the knowledge and competence to perform required duties safely
and contribute to improving system safety performance.
Safe support systems: Identifying, implementing, and maintaining support systems—including
knowledge-sharing networks and systems for responsible reporting—that provide the right information
to the right people at the right time.

Safe place: Designing, constructing, operating, and maintaining the environment of health care to
enhance its efficiency and effectiveness.

Safe patients: Engaging patients and their families in reducing medical errors, improving overall system
safety performance, and maintaining trust and respect.

3.The healthcare system is complex and dynamic, with multiple components and stakeholders working
together to deliver care.

However, this complexity can also lead to errors, causing harm to patients. The goal of building a
safer and more reliable system is to minimize these errors and improve patient safety by creating a
culture of safety, implementing evidence-based practices, addressing human factors, promoting patient
engagement, enhancing data collection and analysis, and adopting risk management strategies. These
efforts should be integrated into all aspects of healthcare delivery, from the organizational level down to
the individual patient encounter, to ensure the highest standards of patient safety.

Building a safer and more reliable healthcare system requires a combination of factors that work
together to create a more robust, resilient, and adaptable system. Which includes

- Culture of Safety: Healthcare organizations need to prioritize patient safety as a core value, and create
an environment where everyone is encouraged to speak up about potential safety concerns.

- Evidence-Based Practices: Providers should adopt proven practices, such as checklists and team
training, that have been shown to improve patient safety.

- Human Factors: Health systems need to account for human limitations in designing care processes and
work environments to reduce the likelihood of errors.

- Data Collection and Analysis: Healthcare organizations should use data-driven approaches to measure
safety performance, identify areas for improvement, and track progress over time.

- Patient Engagement: Healthcare providers should work with patients and families to make sure they
have all the information they need to make informed decisions about their care.

STRATEGIES FOR CREATING A MORE RELIABLE SYSTEM

1. Implementing evidence-based practices: Healthcare providers should adopt proven practices and
techniques that have been shown to improve patient safety, such as checklists, team training, and
electronic medical records.

2. Creating a culture of safety: Healthcare organizations should prioritize patient safety and foster a
culture of open communication, transparency, and continuous improvement.
3. Addressing human factors: Healthcare systems should incorporate human factors engineering
principles to design systems that take into account the limitations and strengths of human behavior,
such as fatigue, distraction, and stress.

4. Promoting patient engagement: Healthcare providers should involve patients and families in decision-
making, providing them with relevant information about their condition and treatment options.

5. Enhancing data collection and analysis: Healthcare systems should collect and analyze data on safety
and quality of care, using this information to identify areas for improvement and track progress over
time.

4.ERROR:-An error refers to an unintentional action or omission that may or may not cause harm to a
patient. Errors can occur at any stage of healthcare delivery, from diagnosis to treatment, and can be
made by any member of the healthcare team, including physicians, nurses, pharmacists, and support
staff.

Errors can be classified into two main types: active errors, which involve an intentional but incorrect
action or decision; and latent errors, which are due to system or environmental factors that increase the
probability of error.

WHILE

HARM:-refers to any negative impact that a healthcare intervention or process has on a patient's
physical, psychological, social, or economic well-being. Harm can occur as a result of errors, adverse
events, or other medical complications, and it can range from minor injuries, like a bruise from a needle,
to life-threatening conditions, like an infection or organ damage.

Harm can also include psychological distress, such as anxiety or depression, social harm, such as
loss of employment or social support, and financial harm, such as medical bills or missed work.

JIGAWA STATE COLLEGE OF NURSING SCIENCES

HADEJIA CAMPUS

QUALITY IMPROVEMENT IN HEALTH CARE AND PATIENT SAFETY

PAPER PRESENTATION

THIRD YEAR FIRST SEMESTER SET 5 STUDENTS NURSES

GROUP MEMBERS (GROUP 5)

1. Hassan Sulaiman

2. Khamisu Yakubu
 3. Khadija Labaran

4. Fatima Nura Isah

5. Maryam Muhammad Inuwa

6. Rukaiya Abdulmajid

7. Fatima Mukhtar Musa

8. Amina Garzali Sulaiman

9. Yasir Muhammad Saleh

COURSE TUTOR: MALAM SULAIMAN MUHAMMAD KANTOMA

Q1. UNDERSTANDING AND LEARNING FROM ERROR (UNDERSTANDING UNSAFE ACT)

Q2. UNDERSTANDING THE SCIENCE OF HUMAN FACTOR

Q3. DESIGNED PRINCIPLES TO REDUCE HUMAN ERROR

Q1. Understanding and learning from error ( understanding unsafe act)

Error

simple definition is: Doing the wrong thing when meaning to do the right thing.”

a more formal definition is: a “Planned sequences of mental or physical activities that fail to achieve
their intended outcomes, when these failures cannot be attributed to the intervention of some chance
agency.”

Situations associated with an increased risk of error

o unfamiliarity with the task*

o inexperience*

o shortage of time

o inadequate checking
o poor procedures

o poor human equipment interface, especially if combined with lack of supervision

Individual factors that predispose to error

o limited memory capacity

o further reduced by:

o fatigue

o stress

o hunger

o illness

o language or cultural factors

o hazardous attitudes

Personal error reduction strategies:

o know yourself

o eat well, sleep well, look after yourself …

o know your environment

o know your task

o preparation and planning

o build “checks” into your routine

Mental preparedness

o assume that errors can and will occur

o identify those circumstances most likely to breed error

o have contingencies in place to cope with problems, interruptions and distractions

o mentally rehearse complex procedures

Summary
o medical error is a complex issue, but error itself is an inevitable part of the human condition

o learning from error is more productive if it is considered at an organizational level

o root cause analysis is a highly structured system approach to incident analysis

Q.2 The Science of human factor

Medicine is devoted to human health and healing, but the science behind why errors occur, and how to
reduce the likelihood of preventable harm to individuals, are well described in human factors literature.
Human factors— is a science dedicated to designing all aspects of a work system to support human
performance and safety. Human factors, also known as ergonomics, uses scientific methods to improve
system performance and prevent accidental harm. The goals of human factors in healthcare are two
folds:

(1) support the cognitive and physical work of healthcare professionals, and

(2) promote high quality, safe care for patients.

Human factors is an established body of science that is positioned to assist with the challenge of
improving healthcare delivery and safety for patients. Human factors and healthcare professionals can
work together to identify problems and solutions that may not be apparent by traditional means. While
human factors does not promise instant solutions for healthcare improvement, it can provide a wealth
of scientific resources for sustainable progress.

~“In healthcare 80% of errors are attributed to human factors at individual level, organisational level, or
commonly both.”~(National Patient Safety Agency, 2008)

Understanding the importance of Human Factors, and how its concepts can be applied by individuals
and teams is fundamental to improving patient safety.

What is Human Factors?

Human Factors encompasses all of the factors that can influence the behaviour and performance of
human beings in a system. It allows us to understand how people perform under different circumstances
and why errors happen.

“Enhancing clinical performance through an understanding of the effects of teamwork, tasks,

equipment, workspace, culture and organisation on human behaviour and abilities and application of
that knowledge in clinical settings” (NHS England, 2013).

Healthcare professionals are human beings and, like all human beings, are fallible. In our personal and
working lives we all make mistakes in the things we do, or forget to do, but the impact of these is often
non-existent, minor or merely creates inconvenience. However, in healthcare there is always the chance
that the consequences could be catastrophic.
Understanding Human Factors helps us build better defences into our systems in order to prevent or
reduce the likelihood of serious error resulting in harm to a patient by:

• Allowing us to understand why we make errors

• Improving our safety culture within teams and the organisation

• Enhancing teamwork and communication

• Identify “what went wrong”

• Helping us predict “what could go wrong” in the future

• Improving the design of the system/processes we work in

Human Factors ‘Dirty Dozen’

The ‘Dirty Dozen’ refers to twelve of the most common factors that influence people to make

mistakes and errors that can potentially lead to harm (Dupont, 1993)

1 Communication

2 Distraction

3 Lack of resources

4 Stress

5 Complacency

6 Lack of teamwork

7 Pressure

8 Situational awareness

9 Lack of knowledge

10 Fatigue

11 Lack of assertiveness

12 Cultural Norms “the way we do things around here”

Q3. Designed principles to reduce human error

Human Error In Nursing Refers To An Action Or Decision That Yields An Undesired Outcome Or A
Significant Deviation From The Intended Result. It Can Also Involve Failing To Carry Out A Planned Action
As Intended Or Incorrectly Applying A Plan To Achieve An Objective.

Human error, in the context of nursing, refers to unintended actions or decision-making that result in a
deviation from standard operating procedures, protocols, or expected outcomes. Such actions or
decisions may lead to adverse events impacting patient care.

Incorrect medication administration, inaccurate patient assessment, and failure to follow infection
control measures are examples of human errors that can occur in nursing clinical placement.

Prevention of human error in a clinical setup comprises a multitude of strategies that revolve around
rethinking workflows, fostering communication, enhancing nurse education and promoting a positive
work environment.

Apart from efficient workflows and communication, continual nurse education is paramount in
preventing human errors. Regular training and education programmes help keep nursing professionals
abreast with the latest practices, guidelines, and protocols, while also acting as a refresher on standard
procedures.

More precise measures and calculations of ways tomorrow reduce human error arise when one points
to five basic ways of reducing error (Kariuki & Lowe 2007):

− Training – 48%

− Procedures – 20%

− Supervision – 13%

− Displays – 13%

− Skills and knowledge – 6% .

JIGAWA STATE COLLEGE OF NURSING SCIENCES

HADEJIA CAMPOS

QUALITY IMPROVEMENT

Group six (6)

Course tutor:Mal. Sulaiman M Kantoma

TOPIC :Professional Accountability and a just culture

Group Members
1.Ahmad Mahmud Bebeji

2.Aliyu Abdullahi

3.Amina Yusuf

4.Fatima Abdulhadi Ismail

5.Fatima yunusa sa'id

6.Ibrahim Yusuf Maina

7.Amina Muhammad Ibrahim

8.Baraatu Sani Haruna

9.Maryam Muhammad Adam

INTRODUCTION

Professional accountability is one of the features of being a professional, being able to accept
accountability for ones actions and being able to justify ones actions, knowing when to and when not to
do something

Minimising risk is a crucial aspect of health and safety and the establishment of a just culture will help to
promote best practice. The foundations of a just culture will require compliance with two principles:

i.The acceptance that human error is inevitable and organisations must review their practices, policies,
and processes to manage the risk of mistakes

ii.Individuals within an organisation should be held accountable for their actions if they knowingly
disobey safety protocol or procedures

1.RESPONDING TO ADVERSE EVENT,ERRO AND HAMF

An adverse event in healthcare is described as “an injury related to medical management, in contrast to
complications of disease

As soon as possible after an adverse event occurs, try to speak with the patient and family members to
apprise them of the situation and to help them understand the implications. Answer questions factually
and directly. Offer emotional support.

How to manage an adverse effects

Where an adverse event has a direct impact on a patient, it should be discussed with them by the most
appropriate member of the clinical team as soon as is practical. Information and support to the patient,
relatives and carers involved should be provided, including information on support systems available.

Responding to Erro and Hamf Report it to your line manager or group leader and make a written record
with them. Assess with your manager whether the Risk Assessment and Client Support Plan was clear
enough to prevent the mistake that occurred. Re-assess or re-word as necessary. Learn from it.

2.STEP BY STEP APPROCH IN RESPONDING TO ADVERSE EFFECTS

i.Acknowledgment

ii.Apology

iii.All the Facts

iv.Assurance and

v.Appropriate Compensation, serve to meet the essential needs of patients and their families.

3.COMMUNICATION, APOLOGY AND RESOLUTION

CARE is about timely communication of important information and supporting families through an
adverse outcome. The hospital or healthcare worker will meet with the injured patient and/or family
member(s) and explain what happened and why; apologize; and discuss what will be done to prevent it
from happening again

Explain what happened and how it happened; it may not be possible to explain why it happened. Let the
family and patient know what will be done to prevent the error from occurring again, and work with the
patient to develop a treatment plan to remedy/mitigate the effects of any injury resulting from the error

1.As soon as possible after an adverse event occurs, try to speak with the patient and family members to
apprise them of the situation and to help them understand the implications.

2.Answer questions factually and directly.

3.Offer emotional support.

4.THE IMPACT OF ADVERSE EVENT ON CARE GIVERS

The patient and the family are the first victim(s) after an event, but the second-victim is the caregiver(s)
involved in the event. Frequently, these individuals may feel personally responsible for the patient
outcome and that they have failed the patient, second-guessing their clinical skills and knowledge base.

JIGAWA STATE COLLEGE OF NURSING SCIENCE,

HADEJIA CAMPUS

QUALITY IMPROVEMENT IN HEALTH CARE AND PATIENT SAFETY

PAPER PRESENTATION

TUTOR: M. SULAIMAN KANTOMA

6 May,2024.

GROUP (7)

Group Members

1.HARISU ABDULLAHI

2.ABUBAKAR ADAMU

3.AISHA YETUNDE LAWAL

4.NAJA'ATU BASHIR

5.SHU'AIBU ABDULLAHI

6.MUBARAK MUHAMMAD SANI

7.BASIRU SULAIMAN

8.AMINA IDRIS BELLO

9.ASMA'U AMINU

Headline

A, definition of just culture

B, building a culture safety

C, understanding and improving organizational culture

INTRODUCTION

Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a
product of faulty organizational cultures, rather than solely brought about by the person or persons
directly involved. In a just culture, after an incident, the question asked is, "What went wrong?" rather
than "Who caused the problem?

DEFINITION OF JUST CULTURE

Just Culture is defined as a system of shared accountability in which organizations are accountable for
the systems they have designed and for responding to the behaviors of their employees in a fair and just
manner.

BUILDING A CULTURE SAFETY

Cultural safety means an environment which is spiritually, socially and emotionally safe, as well as
physically safe for people; where there is no assault, challenge or denial of their identity, of who they
are and what they need.
According to the Occupational Safety and Health Administration (OSHA), developing a strong safety
culture has the single greatest impact on accident reduction of any workplace practice. Therefore,
developing a safety culture should be a top priority for the managers and supervisors at any
organization

HOW TO BUILD A CULTURE SAFETY

1.Evaluate the risks

2. Set goals

3 . include everyone

4. Develop emergency response plans and safety responsibility

5. Implement training

6. Communicate and report

7. Exchange feedback and monitor culture safety

8.continue improving

UNDERSTANDING AND IMPROVING ORGANIZATIONAL CULTURE

Organizational culture is a system of shared assumptions, values, and beliefs, which governs how people
behave in organizations.

These shared values have a strong influence on the people in the organization and dictate how they
dress, act, and perform their jobs. Every organization develops and maintains a unique culture, which
provides guidelines and boundaries for the behavior of the members of the organization.

HOW TO IMPROVE ORGANIZATIONAL CULTURE

1 start with a purpose,mission and value

2 . Evaluate existing culture

3 Align leadership and communication

4.engage employees

5.measure and plan for future initiative

JIGAWA STATE COLLEGE OF NURSING

SCIENCES
 Group presentation

Course:

Quality Improvement In Health Care

And Patient Safety.

GROUP 8

Names of Group Members

Auwal Usman Abdullahi

Rabiu Farouk

Amina Baba Waziri

Rumaisa’u Abubakar

Abba A Gambo

Fatima Auwalu Ibrahim

Aliyu Lawan

Magaji Dahiru Tela

Maryam Ubale

TUTOR:Mal Sulaiman Kantoma

Topic:

Next up (Implementation)

Making Change Stick

Sustaining Improvement

Spread Best Practice For Spray

Next Up (Implementation)

Implementation is the execution of the nursing care plan developed during the planning phase.

The five steps to implementing effective nursing care include reassessing the patient, reviewing and
revising the existing nursing care plan, organizing the resources and care delivery, anticipating and
preventing complications, and implementing nursing interventions.

1.The first step is reassessing the client, a continuous process every time a nurse interacts with a patient,
obtains new data, identifies a new patient need, and modifies the care plan. A reassessment aims to
gather more information to ensure the treatment plan is effective. It helps to decide if the proposed
nursing actions are still appropriate for the patient's level of wellness.

2.The second step is to ensure the validity of nursing diagnoses and the appropriateness of nursing
treatments, review the care plan and compare assessment results. If the patient's status changes and
the nursing diagnosis and accompanying nursing interventions are no longer suitable, the nursing care
plan is modified. An outdated or inadequate care plan compromises quality nursing care. Reviewing and
modifying the care plan enable timely nursing interventions to best meet the patient's needs.

3.Organizing resources and providing care involves assembling a team of experts and equipment. The
proper organization of equipment and personnel makes the ability to provide timely, efficient, and
quality patient care. The patient and the environment must be ready before nursing intervention can
begin.

4.The fourth step includes anticipating and preventing complications arising from the patient's illness or
treatment. The nurse should recognize the risks and select appropriate interventions according to the
situation.

5.The fifth step includes implementing skills that integrate cognitive, psychomotor, and interpersonal
activities.

Nursing requires cognitive, interpersonal, and psychomotor (technical) abilities. Nurses need each type
of skill to implement direct and indirect nursing interventions. Direct care entails the application of
cognitive skills (critical thinking, reflection, clinical judgment, creativity, and so on); interpersonal skills
(caring, communication, comforting, advocacy, and counseling, among others); and technical or
psychomotor abilities (lifting, giving injections, repositioning, etc.).
For indirect care, the treatments are performed through client interactions, such as medication
administration. Likewise, indirect care includes treatments performed away from the client but on
behalf of the client. Examples include communication of patient care with other healthcare providers,
making referrals, advocating, and managing the environment.

Making Change Stick

1.Create a sense of urgency

In order for change to stick, you need excitement. Create this excitement by evaluating and sharing the
benefits as well as the need for the change.

2.Build a guiding coalition

Now that you’ve identified the message, you need messengers and allies. These are trusted,
enthusiastic, champions of your organization. Utilizing team members that others admire will improve
the chances of message acceptance.

3.Form a strategic vision and initiatives

Often, this comes from the top down with input from stakeholders and subject matter experts across
the organization. Developing this vision as a collaborative effort will ensure direction while promoting
buy-in.

4.Enlist a volunteer army

Massive, impactful change is like rowing a Viking ship. It takes an army, working together, pulling hard
(especially at first) to get the ship moving. You’ll need to develop a movement through your message
and use your coalition to get everyone else on board. Address the concerns of those who are slow to
join to facilitate their willing involvement.

5.Enable action by removing barriers

If you empower and excite your organization but don’t allow them to take action or participate you’ll
have committed a grave mistake. These barriers could be restrictions on creativity or slow and inefficient
processes. Either way, their removal is a must.

6.Generate short-term wins

Identify low hanging fruit or opportunities for immediate improvement that will get the ship of change
moving. These will encourage momentum and further buy-in from the group.

7.Sustain accelerations

You got it off the ground, no keep it going! Regular check-ins, evaluations, and adjustments are a must.
Do everything possible to continue the change without moving backward or stopping. It’s hard to get
moving again.

8.Institute change

Reinforce your message and make sure the change is the long term by showing how the urgency and
buy-in accomplished the goals of change. How is everyone’s life easier, did the organization improve,
and how are you positioned to succeed in the future?

- Sustaining Improvement

Sustained Improvement means the organization sustains the improvements in performance for at
least one year after the improvement in performance is first achieved. Sustained Improvement is
documented through the continued measurement of Quality Indicatorsfor at least one year after
the performance improvement project is completed.

8 Ways To Achieve Sustainable Development

Embrace Renewable Energy.

Promote Sustainable Transportation.

Practice Waste Reductionand Recycle

Support Sustainable Agriculture.

Advocate for Conservation.

Educate and Raise Awareness.

Promote Ethical Consumerism.

Empower Women and Girls.

Spread Best practice For spray

A best practice is a standard or set of guidelines that is known to produce good outcomes if followed.
Best practices are related to how to carry out a task or configure something. Strict best practice
guidelines may be set by a governing body or may be internal to an organization. Other best practices
may be more informal and can be set forth in manufacturer's guidance, in published guidelines or even
passed along informally.

In some industries, there may be a legal requirement to follow best practice guidelines. In many
technological fields, however, a best practice usually presents the optimal way to work, how to use a
product or a set of ideals to reach toward. It may not be required to follow a best practice, but an
organization should consult a best practice regularly and follow it wherever possible.