2009 National Patient Safety Goals

Kathleen Killoran, MS, RN-BCCreated 8/18/2009

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OBJECTIVES

Upon completion of this competency, the learner will be able to:

1. Identify the main purpose of the Joint Commission National Patient Safety Goals (NPSGs).

2. Name the three (3) patient identifiers used at AIMMC to

promote patient safety.

3. Review the purpose, process and importance of medication reconciliation.

4. Apply each of the National Patient Safety Goals to

practice.

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The purpose of the Joint Commission’s National Patient Safety Goals

(NPSGs) is to promote specific improvements in

patient safety.

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GOAL # 1Improve the Accuracy of

Patient Identification– We will be moving towards using 3

identifiers• Name• Medical Record Number• Date of Birth

– You know your patients HOWEVER, we are only human. Therefore;

• Confirm patient identifiers prior to administering meds, performing ALL procedures or when transporting to other areas, etc.

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GOAL # 1Improve the Accuracy of Patient

Identification

• Eliminate transfusion errors related to patient misidentification.

• FOLLOW TWO PERSON VERIFICATION PROCESS USING THREE IDENTIFIERS

AND TWO QUALIFIED ASSOCIATES!

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IDENTIFICATION OF IDENTIFICATION OF PATIENTSPATIENTS

Patient Safety Question?

What are the 3 patient

identifiers used at IMMC?

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IDENTIFICATION OF IDENTIFICATION OF PATIENTSPATIENTS

Patient Safety Answer:

The Pt Name, DOB

&

Medical Record # on the armband

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ARMBANDSARMBANDS

Patient Safety Question?

Name 3 occasions when you

should check the patient’s armband?

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ARMBANDSARMBANDSPatient Safety Answer:

Every time you interact with the patient!!! For example:

• At the beginning of your shift.

• Before administering a med.

• Before administering a blood product.

• Before performing any procedure.

• Comparing the chart order before transporting a patient off the unit.

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GOAL #2Improve the effectiveness of

Communication among Caregivers

• “Read-back” all verbal orders, telephone orders and critical test results to confirm accuracy.

• Reporting of critical values in a timely manner.• Standardize the abbreviations, acronyms and symbols

and eliminate unacceptable abbreviations• Implement a standard approach to “Hand off”

communications, including an opportunity to ask and respond to questions

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What does this say?

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We have no idea either…

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DANGEROUS ABBREVIATIONS

DO NOT USE

Ugmcg

Uunit

QDdaily

ccml

IU

International Unit

QOD

Every other day

5.0 mg5mg

.25 mg0.25mg

SC or SQSubQ

MS MSO4 MgSO4

Morphine Sulfate or Magnesium Sulfate

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Handoff communication: follow the 5 P’s & include time to ask and answer questions

• Handoff Situations:– Nursing or allied health shift to shift report– Transfer of care between nurses or allied health to

physician transfer of care – Clinician providing temporary coverage – Interdepartmental handoffs, such as the nursing unit to

Imaging, PACU to the nursing unit: RN to complete Hall Pass tool to communicate information to the other caregivers.

– Transfers of the patient within units of the hospital• 5 P’s

– Patient– Plan– Purpose– Problem– Precautions

GOAL #2 Improve the effectiveness of Communication among Caregivers cont.

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Patient Safety Question?

What is the process of communicating relevant

patient information to another clinician?

GOAL #2 Improve the effectiveness of Communication among Caregivers cont.

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Patient Safety Answer:

“Handoff”

GOAL #2 Improve the effectiveness of Communication among Caregivers cont.

The RN is responsible for completing the

Hall Pass or Patient Transport Tool when the patient leaves the floor

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• Remove concentrated electrolytes from patient care areas.

• Limit the number of drug concentrations.

• Take action to prevent errors with look-alike/sound alike drugs.

• Label syringes, cups and containers on procedure trays

GOAL #3 Improve the Safe Use of

Medications

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Goal # 3: Medication Safety

Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.

Monitor PT/INR when patients are on CoumadinMonitor PTT when patients are receiving IV HeparinEducate patient/family on anticoagulation therapyIndividualize care provided to each patient receiving

anti-coagulant therapy

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Goal # 7: Reduce the Risk of Health Care Acquired

Infections

• Comply with Hand-Hygiene Guidelines– Hands, wrists, and forearms are washed for at

least 15 seconds with soap and water– Alcohol hand-rubs are appropriate for rapid hand

decontamination between patients when hands are

not soiled. – Refer to: Hand Hygiene Policy (90.017.038)

• It is considered a sentinel event if a health care acquired infection (HAI) leads to death or major permanent loss.

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• Implement evidence-based practices to prevent health care acquired infections (HAI) due to multiple drug-resistant organisms (MDRO) in acute care hospitals.

• Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections, surgical site infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections.

• All associates must be educated annually on MDROs, and HAI infection prevention strategies.

Goal # 7: Reduce the Risk of Health Care Acquired Infections

cont.

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Patient Safety Question?

What is the #1 safeguard to

prevent Health Care

Acquired Infections?

cont.

Goal # 7: Reduce the Risk of Health Care Acquired

Infections

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Patient Safety Answer:

Hand Hygiene!

Hand Hygiene!

Hand Hygiene!

See Hand Hygiene Policy (90.017.038)

cont.

Goal # 7: Reduce the Risk of Health Care Acquired

Infections

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• NEW!! We must educate our patients regarding infection prevention strategies. – All patients need basic infection prevention education.– Isolation patients need isolation and isolatable organism

education. – Patients with a central line, urinary catheter, ventilator,

or surgical site need device/procedure related infection prevention education.

• Click links for more information or to view available educational materials.• Or, go to Advocate Online > Illinois Masonic > Departments > Infection Control &

Epidemiology > Associate Education.

Goal # 7: Reduce the Risk of Health Care Acquired

Infections cont.

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Goal 8: Accurately and completely reconcile medications across the continuum of care

• Medication Reconciliation is the process of verifying patient’s medication

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Goal 8: Accurately and completely reconcile medications across the

continuum of care cont.

• Document a complete list of the patient’s current medications on admission, and compare this to the medications provided by the facility.

• Communicate this complete list whenever the patient’s care is transferred to anther area, setting, or healthcare provider.

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What process would have caught this error before it

reached the patient?

• A nurse entered home medications for a patient based on ER documentation which included lasix and furosemide. The Admitting resident ordered “resume all meds” and both were ordered.

Patient Safety Question?

Goal 8: Accurately and completely reconcile medications across the

continuum of care cont.

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Patient Safety Answer:

Medication reconciliation

• Can reduce errors by 46%

• Can reduce Adverse Drug effects up to 20%

Barnstiener JH. Medication reconciliation: transfer of medication information across settings—keeping it free from error. J Infus Nurs. 2005l28(2 suppl):31-6.Rozich, J, et al. Medication safety: one organization’s approach to the challenge. J Clin Outcomes Manag. 2001;8:27-34.

Goal 8: Accurately and completely reconcile medications across the

continuum of care cont.

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Patient Safety Question?

When does Medication

Reconciliation need to be

done for my patients?

Goal 8: Accurately and completely reconcile medications across the

continuum of care cont.

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Goal 8: Accurately and completely reconcile medications across the

continuum of care cont.

Patient Safety Answer:

Upon:1. Admission2. Transfer(s) (different level of care)

3. Discharge

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What is the number one

nursing liability related to

patient safety?

Goal 9: Reduce the risk of patient harm resulting from falls

Patient Safety Question?

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Patient Safety Answer:Patient falls

Goal 9: Reduce the risk of patient harm resulting from falls cont.

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Patient Safety Question?

What are examples of fall risk reduction

interventions?

Goal 9: Reduce the risk of patient harm resulting from falls cont.

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Patient Safety Answer:• Purposeful rounding • Bed in low position at all times• Call light within reach at all times• Side rails up X 2 or X 3 if patient is

at high risk for falls at all times• Proper room lighting• Use of bed alarm technology if

patient is at high risk for falls• Personal items within reach at all

times

Goal 9: Reduce the risk of patient harm resulting from falls cont.

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Goal # 13: Encourage Patient’s Active Involvement in Plan of

Care

Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so.

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Goal # 13: Encourage Patient’s Active Involvement

in Plan of Care cont.

• Communicate expectation that patients and family report safety concerns and encourage reporting

• Provide basic infection prevention and control education including hand hygiene, respiratory hygiene and contact precautions, as applicable. (For more information, click here.)

• Provide Surgical Infection, Patient Identification and Surgical Site Marking Educational Materials, as applicable.

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Goal # 13: Encourage Patient’s Active Involvement

in Plan of Care cont.

– Provide the information to the patient and/or family on the day the patient enters the hospital or within 24 to 48 hours

– Evaluate and document the patient’s understanding of this information.

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Goal # 15: Risk for Suicide

The organization identifies patients at risk for suicide.

• All patients presenting at the All patients presenting at the Emergency Department will be Emergency Department will be screened by the nurse for suicide risk screened by the nurse for suicide risk

•The admitting RN will ask the suicide The admitting RN will ask the suicide screening question on patientsscreening question on patients

•Implement Suicide Precautions Implement Suicide Precautions immediately if the patient is at risk of immediately if the patient is at risk of harming selfharming self

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SUICIDE SCREENING DOCUMENTATION

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Goal #16: Improve recognition and response to changes in a patient’s

condition. The organization selects a suitable

method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

At AIMMC, staff can directly request additional help from

the

Rapid Response Team (RRT), a specially trained team, if the patient’s condition worsens.

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2009 JCAHO National Patient Safety Goals

-&-Universal Protocol # 1Universal Protocol # 1

Elimination Wrong Site, Procedure, Person, Surgery– Timeouts

– EVERYONE participates!!!

– Site Marking

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What is Advocate’s RED RULE?

?

2009 JCAHO National Patient Safety Goals

cont.

Patient Safety Question?

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Time OUT

2009 JCAHO National Patient Safety Goals

cont.

Patient Safety Answer:

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Universal Protocol, the Three Steps…

Step 1:

The preoperative/procedure VERIFICATION process

-Correct patient

-Correct Procedure

-Correct Site

Step 2:

The operative/procedure site MARKING

Step 3:

A ‘TIME OUT’ immediately before starting the procedure

2009 JCAHO National Patient Safety Goals

cont.

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Marking the site

The operating physician/surgeon discusses surgery/procedure with patient, verifies and confirms site with consent form and patient’s statement of planned procedure

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Rule of thumb: Anything that may require a consent and/or is a “high risk” procedure requires a TIME-OUT

Don’t forget! The “TIME-OUT process applies to procedures OUTSIDE the OR as well!

2009 JCAHO National Patient Safety Goals

cont.

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PATIENT SAFETY REPORTING

Patient Safety Question?

What have you done lately for patient safety?

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PATIENT SAFETY REPORTING

Patient Safety Answer:

Remember to submit• A Patient Safety

Event Report via Remote Data Entry (RDE) to identify areas for process improvement.

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REFERENCESREFERENCES::

Click to review Advocate Policy #:

90.017.017: Fall Prevention

90.017.018: Mandatory Time Out

90.017.038 Hand Hygiene Policy

Click to review Online Resources:

National Patient Safety Goals

www.jointcommission.org

Patient Education of Infection Prevention Strategies

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• You are now ready to complete the 2009 Joint Commission National Patient Safety Goals Quiz.

Click on the Quiz and select the best answers.

RNs 80% correct (10/12) is required for successful completion.

RNs Click here for quiz.