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UNIT6 | Healthassessment

Vital signassessment | Chapter20

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Review and carry out the standard steps for all clinical skills/interventions Detection System (ADDS) chart, Figure 20.5). While the ADDS chart should allow for early recognition of an indi- vidual’s deterioration through colour coding, it is essential that all nurses have the underpinning clinical knowledge and clinical judgment to respond appropriately (see Clinical Int rest Box 20.10). UNIT6 | Healthassessment 430

Clinical Skills are in a referenced, step-by-step format emphasising the nursing process and include rationales for each step

CLINICAL INTEREST BOX 20.10 Clinical deterioration

CLINICAL SKILL 20.1 Assessing body temperature

Quality and safety in healthcare | Chapter 7 Review Questions 1. What is your understanding of quality in healthcare? 2. What does accreditation mean for a healthcare facility? 3. explain: > Benchmarking > Clinical indicators. 4. how is patient safety different from quality? 5. Why is the perspective of the person who was harmed important when measuring severity of harm? 6. What is the difference between active and latent errors? 7. What is meant by ‘contributing factors’? 8. Why is standardisation considered a powerful patient safety initiative? a Suggest a reason that, on the day of her admission, Mrs Seagal’s vital signs were slightly elevated. b Suggest a reason why Mrs Seagal’s vital signs had decreased on the preoperative assessment. c What could you infer from the overall change in vital signs in the postoperative period? d What further objective and subjective data would you need to collect to confirm your assumptions? 10. Chart the above observations (i Q 9) on the dult Deterioration Detection System chart (Figure 20.5). Identify if an scal tion of care is required for this individual. If so, what type of escalation and why? Answer guide for the Review Questions, Critical Thinking Exercises, Decision-Making Framework Exercises and Critical Thinking Questions in Case Studies are hosted on Evolve: http://evolve.elsevier.com/AU/Koutoukidis/Tabbner/ Vital si ns are generally ssessed when an individual is admitted to a healthcare agency, to establish baseline data, when there is a change r possibility of change in the individu l’s condition and as part of routine care. Data CRITICAL THINKING EXERCISE 20.4 1. You are working in a nursing home and the Registered Nurse asks you to complete a blood pressure reading on a new admission. The individual is morbidly obese and the cuff only just fits around the individual’s arm. How would this affec the accuracy o the reading? 2. You are working in a community he lth centre a d y u need to complete a blo d pressure readng on a 75-year- old female, Rita Smith. Rita wants to keep her thick woollen jumper on while you complete the blood pressure. How would you respond to Rita’s request? 3. You are caring for Renae Polontee, a 30-year-old apprentice chef, who has accidentally cut off her right thumb. There was considerable blo d loss prior to first aid administered at the scene. Would you expect Renae to be hypotensive or hypertensive? Justify your answer. 4. Which arm would you assess Renae’s blood pressure on and why? Answer guide for the Review Questions, Critical Thinking Exercises, Decision-Making Framework Exercises and Critical Thinking Questions in Case Studies are hosted on Evolve: http://evolve.elsevier.com/AU/Koutoukidis/Tabbner/ 148 UNIT 2 | The contemporary healthcare environment References Australian Commission on Safety and Quality in Health Care (ACSQHC). (2010). National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration . Retrieved from: < http://www.safetyandquality.gov.au/our-work/ recognising-and-responding-to-clinical-deterioration/implementing- r-and-r-systems/implementation-guide/ > . —— (2012). Recognising and responding to clinical deterioration in acute health care – Standard 9 fact sheet, Retrieved from: < http:// www.safetyandquality.gov.au/publications/nsqhs-standards- fact-sheet-standard-9-recognising-and-responding-to-clinical- deterioration-in-acute-health-care/ > . Australian Institute of Health and Welfare (AIHW). (2015). High blood pressure . Retrieved on 25 February 2015 from: < http:// www.aihw.gov.au/high-blood-pressure/ > . Chua, W. L., Mackey, S., Ng, E. K. C., et al. (2013). Front line nurses’ experiences with deteriorating ward patients: a qualitative study. International Nursing Review , 60 (4), 501–509. Clarke, C. (2014). Promoting the 6Cs of nursing in patient assessment. Nursing Standard , 28 (44), 52–59. Clinical Excellence Commission (CEC). (2012). Clinical Excellence Commission Sepsis Kills Program: Adult Blood Culture Sampling . Retrieved from: < http://www.cec.health.nsw.gov.au/programs/sepsis/ sepsis-tools > . NMBA Decision-making Framework considerations: 1. am I educated? 2. am I authorised? 3. am I competent? If you answer ‘no’ to any of these, do not perform that activity. Seek guidance and support from your teacher/a nurse team leader/clinical facilitator/educator. Communication is extremely important in the event of clinical deterioration, and it is always essential to follow ISBAR handover when escalating the care of an individual. ISBAR handover will ensure that all information is passed on efficiently and correctly so the individual can be managed appropriately (see Chapter 8 on Communication for more information on ISBAR). 430 UNIT6 | Healthassessment Detection System (ADDS) chart, Figure 20.5). While the ADDS chart should allow for early recognition of an indi- vidual’s deterioration through colour coding, it is essential that all nurses have the underpinning clinical knowledge and clinical judgment to respond appropriately (see Clinical Interest Box 20.10). Communication is extremely important in the event of clinical deterioration, and it is always essential to follow ISBAR handover when escalating the care of an individual. ISBAR handover will ensure that all information is passed on effic ently and corre tly s the individual can be managed appropriately (see Chapter 8 on Communicatio for more informatio on ISBAR). Detection System (ADDS) chart, Figure 20.5). While the ADDS chart should allow for early recognition of an indi- vidual’s deterioration through colour coding, it is essential that all nurses ave the underpinning clinical k owledge nd clinical judgment to respond appropriately (see Cli ic l Interest Box 20.10). Communication is xtremely impo t nt in the eve t of clinical deterioration, and it is always essential to follow ISBAR handover when escalating the care of an individual. ISBAR handover will ensure hat ll information is passed on efficiently and correctly o the individual can be managed appropri tely (see Chapte 8 on Communication for m re information on ISBAR). Skill activity Before assessing body temperature assess the individual for temperature alterations and anything that may interfere with the accuracy of temperature measurement Wait 15–20 minutes if the individual has smoked or ingested hot or cold foods or fluids DECISION-MAKING FRAMEWORK EXERCISE 20.1 You have just been employed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign assessmentononeofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm; all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the last time she passed urine. After approaching the medical officer and handing over the individual and current situation, the medical officer asks you to insert an IV cannula and orders the commencement of IV therapy. Using the decision-making framework: 1. From the interventions ordered by the medical officer, are all interventions within your current scope of practice? 2. What actions are required in this situation? 3. How would you document the above situation in your nursing notes? Vital signassessment | Chapter20 DECISION-MAKING FRAMEWORK EXERCISE 20.1 You have just been employed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign assessmentonon ofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm; all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the last time sh passe urine. After approaching the medical offic r and handing ov r the individual and current situ tion, the medical officer asks you to insert an IV cannula and rders the c mmencement of IV therapy. Using the decision-making framework: 1. From the interventions ordered by the medical officer, are all interventions wit in your current scope f practice? 2. What actions are required in this situation? 3. H w would you do ument the above situation in your nursing notes? ‘Individual admitted with pneumonia. Became short of breath and had low oxygen levels. Staff did not call for assistance ina timelyway.The individualdied’ (ACSQHC 2008). It is imperative that nursing staff identify clinical deteriorations and act accordingly for individual safety. DECISION-MAKING FRAMEWORK EXERCISE 20.1 You have just b en mployed as a graduate Enrolled Nurse at a healthcare facility. You are completing a vital sign assessmentononeofyourallocated individuals,andyoudiscoverherbloodpressure is98/55andheart rate is95 bpm; all other vital signs are in normal limits. The individual states she does feel a bit light headed and can’t remember the last tim she pass d urine. After approaching the medical officer and handing over the individual and current situation, the medical officer asks you to insert an IV cannula and orders the commencement of IV therapy. Using the decision-making framework: 1. From the interventions ordered by the medical officer, are all interventions within your current scope of practice? 2. What actions are required in this situation? 3. How would you document the above situation in your nursing notes? UNIT6 | Healthassessment Cooper, K., & Gosnell, K. (2015). Foundations and adult health nursing (7th ed.). St Louis: Elsevier, Mosby. Crisp, J.,Taylor, C., Douglas, ., et al. (2013). Potte a d P rry’s fundamentals of nursing (4th ed.). Sydney: Elsevier. Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing , 21 (10), 621–625. El-Radhi, A. S. (2014). Determining f ver in children: t e search for an ideal thermometer. British Journal of Nursing , 23 (2), 91–94. Control-of-breathing > . Kunde, L. (2014). Accidental Hypothe mia: Management. Joanna Briggs Institute Evidence Based Nursing and Midwifery , evidenc summaries, revision 0. Marik, P. E. (2013). Noninvasiv Cardiac Output Monitors: A State-of the-Art Review. Journal of Cardiothoracic andVascular Anesthesia , 27 (1), 121–134. McCallum, L., & Higgins, D. (2012). Measuring body temperature. NursingTimes , 108 , 20–22. Retrieved from < http://search .proquest.com/docview/1178995978?accou tid = 132066 > . physical signs and symptoms of temperature alterations may be present such as the individual being flushed or shivering If using an oral thermometer, intake of some foods can cause inaccurate readings If using a tympanic thermometer, hearing aids can increase temperature readings Different individuals will have different requirements due to their health conditions Determine appropriate temperature site and temperature device for the individual Assessing body temperature with a tympanic membrane electronic thermometer assist the individual in assuming a comfortable position, with head turned away from the nurse Review Questions 1. What are the factors that can affect vital signs? 2. What are the advantag s a d isadv ntages of using each body temperature site? ensures comfort and exposes auditory canal for accurate temperature measurement. ensures individual safety and comfort Lens cover of speculum must not be impeded by earwax (will not obtain an accurate measurement). Switch to other ear or select an alternative measurement site Base provides battery power. Soft plastic probe cover prevents transmission of microorganisms Observe for ear wax (cerumen) in individual’s ear canal the less acute the angle of approach the better the probe will seal inside the auditory canal 5. Ms hawdon has just given birth to a healthy baby boy. after the delivery she has a postpartum haemorrhage and loses 1200 mL of blood. Would you expect Ms hawdon’s blood pressure to increase or decrease? State the reason for your answer. 6. Identify two sites for taking blood pressure in an adult. Describe the procedure. 7. What are the three (3) characteristics of a pulse? What characteristic(s) would be altered during atrial fibrillation and why? 8. Mr ryan, 82 years of age, has just been admitted with shortness of breath. Describe the observation you would conduct. 9. review the information in the observation chart below, then answer the questions that follow. PROGRESS NOTE EXAMPLE 20.1 Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO 2 99% on RA, Temp 36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT: tolerating diet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered independently. Supervision when ambulating with nil mobility aids. Legal: medication given as per medication chart. Zoe Morgan (Morgan) EN PROGRESS NOTE EXAMPLE 20.1 Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO 2 99% on RA, Temp 36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT: toleratin iet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered independently. Su rvision when ambulating with nil mobility aids. Legal: medication given as per medication chart. Z e Morgan (Morgan) EN Musselman, M. E., & Saely, S. (2013). Diagnosis and treatment of drug-i duced hyperther ia. American Society of Health-System Pharmacists , 70 (1), 34–42. Perry, A., Pot er, P, & Elkin, M. (2012). Nursing interventions an clinical skills ( th ed.). St. Louis: Elsevier. Philip, K., Richardson, R., & Cohen, M. (2013). Staff perceptions of respiratory rate measurement in a general hospital. British Journal of Nursing , 22 (10), 570–574. Potter, P. A., Perry, A. G., et al. (2013). Fundamentals of nursing (8th ed.). St Louis: Elsevier, M sby. Depression of scan button causes infrared energy to be detected. Otoscope tip must stay in situ until signal occurs to ensure accurate measurement PROGRESS NOTE EXAMPLE 20.1 04/06/2016 1300 hrs Nursing: CNS: pt alert and orientated to person, place and time. Nil complaints of pain. CVS: complained of feeling dizzy when ambulating, vital signs checked—BP 101/59, HR 66, RR 15, SaO 2 99% on RA, Temp 36.5. BP monitored 2/24, oral fluids encouraged and ambulation supervised. BP increased to 115/70. GIT: tolerating diet and fluids. BNO. Renal: pt voiding on sensation. FBC maintained. ADLs: showered independently. Supervision when ambulating with nil mobility aids. Legal: medication given as per medication chart. Zoe Morgan (Morgan) EN 3. What characteristics should be included in a respiratory assessment? 4. What is an early indicator of a clinical deterioration in an individual? t—36.7, p—100, r—22, B/p—140/90: 1600 hrs t—36.4, p—80, r—18, B/p—130/70: 0800 hrs t—35.8, p—60, r—16, B/p—120/70: 1400 hrs t—36.4, p—80, r—18, B/p—130/70: 1800 hrs t—36.4, p—76, r—18, B/p—120/70: 2000 hrs CLINICAL INTEREST BOX 20.10 Clinical deterioration 432 Equipment: appropriate thermometer Disposable probe cover or sleeve pen (blue/black) and observation chart ‘Individual admitted with pneumonia. Became short of breath and had low oxygen levels. Staff did not call for assistance ina timelyway.The individualdied’ (ACSQHC 2008). It is imperative that nursing staff identify clinical deteriorations and act accordingly for individual safety. CLINICAL INTEREST BOX 20.10 Clinical deterioration ‘Indivdu a mitted with pneumonia. Became short of breath and had low oxygen levels. Staff did not call for assistance ina timelyway.The individualdied’ (ACSQHC 2008). It is imperative that nursing staff identify clinical deteriorations and act accordingly for individual safety. Rationale remove thermometer from charging base and slide disposable speculum cover over otoscope-like tip until it locks into place, being careful not to touch lens cover If holding handheld unit with right hand, obtain temperature from individual’s right ear; left-handed persons should obtain temperature from individual’s left ear Insert speculum into ear canal, following manufacturer’s instructions for tympanic probe positioning. pull pinna backwards, up and out for an adult, move thermometer in a figure-eight pattern, fit probe snugly in canal and do not move, point towards the nose as soon as probe is in place, depress scan button. Leave thermometer probe in place until an audible signal is given and individual’s temperature appears on the digital display Carefully remove speculum from auditory meatus. push ejection button on unit to discard plastic probe cover into an appropriate receptacle Vital si ns r flec changes in b dy function and therefore provide the nurse with important information about the clinical health status of an individual. Various sites and methods can be used to assess vital signs, and the nurse selects the site and method that is safest for the individual and that will provide the most accurate measurement pos- sible. It is important to note that changes in one vital sign can trigger changes in other vital signs. Vital signs are generally assessed when an individual is admitted to a healthcare agency, to establish baseline data, when there is a change or possibility of change in the individual’s condition and as part of routine care. Data Summary admission obs preoperative obs postoperative obs Day 1 post op Vital signs reflect changes in body function and therefore provide the nurse with important information about the clinical health status of an individual. Various sites and methods can be used to assess vital signs, and the nurse selects the site and method that is safest for the individual and that will provide the most accurate measurement pos- sible. It is important to note that changes in one vital sign can trigger changes in other vital signs. Summary 04/06/2016 1300 hrs Vital signs reflect chang s in body function and therefore provide the nurse with important information about the clinical health status of an individual. Various sit s and methods can be used to assess vital signs, and the nurs selects the site and method that is safest for the individual and that will provide the most accurate measurem nt pos- ible. It is important to note t t changes in one vital sign can trigger changes in other vital signs. Vital signs are generally assessed when an individual is admitt d to a healthcar agency, to establish baseline data, when there is change or possibility of change in the individual’s condition and as part f routine care. Dat Summary 04/06/2016 1300 hrs Fisher, D., & King, L. (2013). An integrative literature review on preparing nursing students through simulation to recognize and respond to the dete iorating patie . Jou n l of Adva ced Nursing , 69 (11), 2375–2388. do:10.1111/jan.12174. Flynn Makic, M. B., Martin, S. A., Burns, S., et al. (2013). Putting Evidence Into Nursing Practic : FourTraditional Practices Not Supported by the Evidence. Critical Care Nurse , 33 (2), 28–43. Frese, E., Fick, A., & Sadowsky, S. (2011). Blood Pressure Measurement Guidelines for Physical Therapists. Cardiopulmon ry Physical Therapy Jou nal , 22 (2), 5–12. Grai ger, A. (2013). Principles of temperat re monitoring. Nursing Standard , 27 (50), 48–55. Gregory, J. (2014). Dealing with acute and chronic pain: part one—asses me t. Journal of Clinic l Nursing , 28 (4), 83–86. Hill Bailey, P., McMillan Boyles, C., Duff Cloutier, J., et al. (2013). Best practice in nursing care of dyspnea: The 6th vital sign in individuals with COPD. Journ l of Nursing Education and Practice , 3 (1), 108–122. doi:10.5430/jnep.v3n1 108. Kinn y, S. (2014). The Royal C ildren’s Ho pit l Melb urne, clinical gui elines (Nursing), Observation and continuous monitoring. Retrieved from: < http://www.rch.org.au/rchcpg/hospital_clinical_ guideline_index/Observation_and_Continuous_Monitoring/ > . Klocke, R. A. (2014). Huma respiratory sy tem – Contr l of breath n . Retrieved on 20 February 2015 from: < http://www. rtannica .com/EBchecked/topic/499530/human-respiratory-system/66138/ return handheld unit to charging base Day 2 post op Day 3 post op Correct positioning of probe will ensure accurate readings as there will be maximum exposure of the tympanic membrane obtained from measurements of vital signs are then used to plan and implement appropriate nursing interventions, as well as to evaluate an individual’s response to nursing interventions or prescribed medical therapy. It is important for the nurse to have knowledge of the normal ranges of vital signs and of the factors that regulate and influence vital signs, as this helps them interpret the measurements that deviate from normal. It is also imperative that the nurse has the underpinning clinical knowledge and judg- ment to recognise and respond to a deteriorating indi- vidual and act accordingly to maintain the clinical health status (ACSQHC 2012). obtained from measurements of vital signs are then used to plan and implement appropriate nursing interventions, as well as to evaluate an individual’s response to nursing interventions or prescribed medical ther py. It is important for the nurse to have knowledge of the normal ranges of vital signs and of the factors that regulate and influence vital signs, as this helps them interpret the measurements that deviate from normal. It is also imperative that the nurse has the underpinning clinical knowledge and judg- ment to recognise and espond to a de eriorating indi- vidual and act accordingly to maintain the clinical health status (ACSQHC 2012). obtained from measurements of vital signs are then used to plan and im lement appropriate nursing interventions, as well a to evaluate an i dividu l’s response to u ing interventi ns or prescribed medical therapy. It is important for the nurse to have k owledge of the normal ra ges of vital signs and of the factors that regulate nd influence vital signs, as this helps them interpret the measurements th t deviate fr m normal. It is also imp r tive that the nurse has the under inning clinical knowledge and judg- ment to recognise and respond t a d teriorating indi- vidual nd act ccordingly to maintain th clinical health status (ACSQHC 2012). Purling, A., & King, L. (2012). A literature review: gra uate nurses’ preparedness for recognising and responding to th deteriorati g pati nt. Journal of Clinical Nursing , 21 , 3451–3465. doi:10.1111/j.1365-2702.2012.04348. Rebeiro, G., Jack, L., & Scully, N. (2012). Potter and Perry’s fundament ls of nursing clinical skills workbook . Sydney: Elsevier. Sahin, S. H., Duran, R., Sut, N., et al. (2012). C mparison of t mporal art ry, nasopharyngeal, and axillary temperature measurement during anesthesia in children. Journal of Clinical Anesthesia , 24 (8), 647–651. doi:10.1016/j.jclinane.2012.05.003. Scaravilli, V., Bonacina, D., & Citerio, G. (2012). R wa ming: facts an myths from the systemic per pective. Critical Care , 16 (2), 1–42. reduces transmission of microorganisms protects sensor tip from damage and keeps unit charged ready for next use Continued 431 t—36.4, p—80, r—20, B/p—130/70: 1000 hrs t—36.4, p—80, r—20, B/p—130/70: 1800 hrs t—36.8, p—88, r—20, B/p—130/70: 2200 hrs t—37.0, p—88, r—20, B/p—130/70: 0100 hrs t—37.8, p—90, r—22, B/p—135/80: 1400 hrs t—38.5, p—90, r—24, B/p—135/90: 2000 hrs t—37.4, p—88, r—22, B/p—135/70: 0700 hrs 147

Decision-making Framework Exercises are specific to the chapter content and the EN scope of practice

Review Questions are specific to the assist students with comprehension and review of the chapter content

Progress Note Examples show how a student might document care of an individual while on placement

Summary highlights key points in the chapter content

Critical Thinking Exercises stimulate the student to think critically and problem solve

References and Recommended Reading

Smith, R. (2001). Editorial: one bristol, but there could have been many. British Medical Journal , 323 , 179–180. Wakefield, J. G., McLaws, M. L., Whitby, M., et al. (2008). Patient safety culture: factors that influence clinician involvement in patient safety behaviours. Quality and Safety in Health Care , doi:10.1136/ qshc.2008.030700. Recommended Reading Australian Commission on Safety and Quality in Healthcare. (2014). Vital Signs 2014 < http://www.safetyandquality.gov.au/wp-content/ uploads/2014/10/Vital-Signs-2014-web.pdf > . Australian Commission on Safety and Quality in Health Care (ACSQHC). (2012). Australian Safety and Quality Goals for Health Care: Development and Consultation Report Accessed 14.03.15 < http://www.s fetyandquality.gov.au/wp-content/uploads/2012/08/ Safety- nd-Quality-Goals-Development-and-consultation- report.pdf > . Braithwaite, J., Healy, J., & Dw n, K. (2005). The Governance of Health Safe y and Quality , Commonwealth of Australia , < https://www.anu.edu.au/fellows/jbraithwaite/_documents/Reports/ Governance_Health_2005.pdf > . Brand, C. A., Ibrahim, J. E., Cameron, P. A., et al. (2008). Standards for health care: a necessary but unknown quantity. Medical Journal of Australia , 189 (5), 257–260. < https://www.mj .com.au/ journal/2008/189/5/ standards-health-care-necessary-unknown-quantity > . Joseph, A., & Malone, E. (2012). The Environment: An Often Unconsidered Patient Safety Tool < http://webmm.ahrq.gov/ perspective.aspx?perspectiveID = 130 > . Leape, L. (2011). Key Lessons in Patient Safety < https:// www.youtube.com/watch?v = oSoklPmHCkg > . Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing. Theory and application . USA: Wolters Kluwer Lippincott, Williams and Wilkins Health.

McNicol, E., & Hamer, S. (2006). Leadership and management. A three dimensional approach . United Kingdom: Nelson Thornes. Mitchell, P. (2013). Safer care – human factors in healthcare: Course handbook . UK: Swan & Horn. N tional Pati t Safety Agency. ( 004). Seven Steps to Patient Safety < http://www.nrls.npsa.nhs.uk/res urces/collections/seven-steps-to- patient-safety/?entryid45 = 59787 > . Royal College of Physicians and Surgeons of Canada. (2003). Canadian Patient Safety Dictionary < http://www.royalcollege.ca/ portal/page/portal/rc/common/documents/publications/patient_ safety_dictionary_e.pdf > Accessed 30.08.03. The Commonwealth Fund. (2011). Why not the Best? Results from the Nati nal Scorecard on U.S. Health System Performance 2011 < http:// www.commonwealthfund.org/~/media/files/publications/fund- report/2011/oct/1500_wntb_natl_scorecard_2011_web_v2.pdf > . Wakefield, J. G., & Jorm, C. (2009). Patient safety—a balanced measurement framework. Australian Health Review , 33 (3), 382–389, < http://www.academia.edu/3344391/ Patient_safety_a_balanced_measurement_framework > . Online Resources Institute for Healthcare Improvement http://www.ihi.org/topics/ patientsafety/pages/default.aspx http://www.ihi.org/resources/Pages/Changes/ DevelopaCultureofSafety.aspx Joint Commission Center for Transforming Care http://www.jointcommission.org National Health Service UK Patient Safety Centre http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/ http://patientsafety.health.org.uk Joint Commission Center for Transforming Care http://www.jointcommission.org National Health Service UK Patient Safety Centre Online resources provide useful web links r lat d to the chapter content

Eagar, K., Sansoni, J., Loggie, C., et al. (2013). A Literature Review on Integrating Quality and Safety into Hospital Pricing Systems . Centre for Health Service Development, Australian Health Service Research Institute, University of Wollongong < http:// www.safetyandquality.gov.au/wp-content/uploads/2012/12/ Literature-Review-on-Integrating-Quality-and-Safety-into-Hospital -Pricing-Systems1.pdf > . Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century < http://www.nap.edu/ catalog/10027.html > Accessed 14.03.15. Jeyaratnam, E., & Jackson-Webb, F. (2014). Infographic: Comparing International Health Systems < https://theconversation.com/ infographic-comparing-international-health-systems-30784 > Accessed 30.08.15. Kay, J. F. L. (2007). Health care benchmarking. Hong Kong Medical Diary Vol 12 no 2 February < http://www.fmshk.org/database/ articles/06mbdrflkay.pdf > . Accessed 14.08.15. Latner, A. W. (2015). Medicare penalizes hospitals for preventable medical errors < http://www.clinicaladvisor.com/legal-advisor/ medicare-penalizes-hospitals-for-preventable-medical-errors/ article/394354/ > Accessed 12.08.15. Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association , 273 (23), 1851–1857. Malone, B. (2004). Pursuing patient Safety. Quality and Safety in Health Care , 13 , 86–87. doi:10.1136/qshc.2003.009498. < http://qualitysafety.bmj.com/content/13/2/86.2.full .pdf + html > . Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition . (2003). by Saunders, an imprint of Elsevier, Inc. All rights reserved. National Health Performance Committee. (2001). National Health Performance Framework report: August 2001 < http:// www.aihw.gov.au/publication-detail/?id = 6442467275 > , released: 7 Sep 2001 author: ISSN 1-876532-64-5; Cat. no. AIHW 7112; Accessed 14.03.15.

encourage further reading within each chapter topic

References Agency for Healthcare Research and Quality (AHRQ). (2015). Patient safety primers, Human Factors Engineering < http://psnet.ahrq.gov/ primer.aspx?primerID = 20 > Accessed 23.08.15. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2010). Australian Safety and Quality Framework for Health Care 2010 < http://www.safetyandquality.gov.au/national- priorities/australian-safety-and-quality-framework-for-health-care/ > Accessed 14.03.15. —— (2011). Implementation Toolkit for Clinical Handover Improvement < http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/ ImplementationToolkitforClinicalHandoverImprovement.pdf > . —— (2012). National Safety and Quality Health Service Standards < http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/ NSQHS-Standards-Sept-2012.pdf > Accessed 14.03.15. Australian Institute of Health and Welfare. (2014). Australia’s health 2014. Australia’s health series no. 14. Cat. no. AUS 178. Canberra: AIHW. < http://www.aihw.gov.au/publication- detail/?id = 60129547205 > Accessed 15.03.15. —— (2015). < http://www.aihw.gov.au/sqhc-definitions/ > . Australian Medical Association. (2012). Clinical Indicators – 2012 < https://ama.com.au/position-statement/clinical-indicators-2012 > Accessed 15.08.15. Buttell, P., Hendler, R., & Daley, J. (2007). The Business of Healthcare Chapter 3. Quality in Healthcare: Concepts and Practice < http://healthcarecollaboration.com/docs/quality_buttell.pdf > Retrieved 23.05.15. Curtis, K., Tzannes, A., & Rudge, T. (2011). How to talk to doctors – a guide for effective communication. International Nursing Review , 58 , 13–20. Dingley, C., Daugherty, K., Derieg, M., et al. (2008). Chapter 3 Improving Patient Safety Through Provider Communication Strategy Enhancements in Advances in Patient Safety: New Directions and Alternative Approaches (Vol 3: Performance and Tools) In Henriksen, K, Battles JB, Keyes, MA et al, Editors. Agency for Health Care and Research < http://www.ncbi.nlm.nih.gov/books/NBK43663/ > Accessed 15.08.15. Duckett, S. (2014). Australian Healthcare. Where do we stand 148

UNIT 2 | The contemporary healthcare environment

Online Resources Institute for Healthcare Improvement http://www.ihi.org/t pics/ patients fety/pages/default.aspx http://www.ihi.org/resources/Pages/Changes/ DevelopaCultureofSafety.aspx Joint Commission Center for Transforming Care http://www.jointcommission.org National Health Service UK Pati nt Safety Centr http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/ http://patientsafety.health.org.uk Recommended Reading Australian Commission on Safety d Quality in Healthcare. (2014). Vital Signs 2014 < http://www.saf tyandquality.gov. u/wp-content/ uploads/2014/10/Vital-Signs-2014-web.pdf > . Australian Commission on Safety and Quality in Health Care

http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/ http://patientsafety.health.org.uk handbook . UK: Swan & Horn. National Patient Safety Agency. (2004). Seven Steps to Patient Safety < http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-t o patient-safety/?entryid45 = 59787 > . Royal College of Physicians and Surgeons of Canada. (2003). Canadian Pat ent Safety Dictionary < http://www.royalcollege.ca/ portal/page/portal/rc/common/documents/publications/patient_ safety_dictionary_e.pdf > Accessed 30.08.03. The Commonwealth Fund. (2011). Why not the Best? Results from the National Scorecard on U.S. Health System Performance 2011 < http:// www.commonwealthfund.org/~/media/files/publications/ fund-report/2011/ oct/1500_wn b_natl_scorecard_2011_web_v2.pdf > . Wakefield, J. G., & Jorm, C. (2009). Patient safety—a balanced me surement framework. Australian Health Review , 33 (3), 382–389, < http://www.academia.edu/3344391/ Patient_safety_a_balanced_measurement_framework > . Online Resources Institute for Healthcare Improvement http://www.ihi.org/topics/ patientsafety/pages/default.aspx http://www.ihi.org/resources/Pages/Changes/ DevelopaCultureofSafety.aspx

Empowering Knowledge | Reason, J. (1990). Human error . UK: Cambridge University Press. —— (2000). Human error models and management British Medical Journal Mar 18 ; 320 (7237): 768–770. < http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/ > Accessed 12 August 2015. (ACSQHC). (2012). Australian Saf ty and Quality Goals for Health Care: Development and Consultation Report Accessed 14.03.15 < http://www.safetyandquality.gov.au/wp-content/uploads/2012/08/ Safety-and-Quality-Goals-Development-and-consultation- report.pdf > . Braithwaite, J., Healy, J., & Dwan, K. (2005). The Governance of Health Safety and Quality , Commonwealth of Australia , < https://www.anu.edu.au/fellows/jbraithwaite/_documents/Reports/ Governance_Health_2005.pdf > .

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