Patient Patient SafetySafety

20102010

Patient SafetyPatient Safety……is our jobis our job

TEAMWORK

Individual accountability and vigilance is important, but it is not

enough!

To build a culture of safety we have to work as a team.

Cooperation Coordination

Communication+

Teamwork

+

Cooperation

TeamworkEach team member has a specific job

to do. By cooperating, we can help each other and achieve our #1 goal: safe patient care

TeamworkWhenever patient care is

transferred from shift to shift, unit to unit, or department to department, the risk of errors sharply increases.

Communication is one key that can help prevent these errors.

Communication

Coordination

Don’t assume anything. Clearly define roles & responsibilities.Coordinating with colleagues, staff, patient’s, and the family is an important part of safety.

Teamwork

Patient SafetyPatient Safety

Requires a commitment from YOU!

Patients’ expectations have changed … They want to know that they are safe. They want to know that you are their advocate. They want to know your “practice” is safe.

Regulatory agencies are requiring and surveying safe practices. TJC, CMS, TDH, insurance groups

20102010

National Patient National Patient Safety GoalsSafety Goals

Although there were no new goals developed, there were significant changes made to the goals.

Elements of some of the goals and a few entire goals were moved to other standards. ***NOTE- this does not mean they will not be scored, just means they will not be scored as a patient safety goal.

National Patient Safety GoalsNational Patient Safety Goals

National Patient Safety GoalsNational Patient Safety Goals

NPSG 01: Improve the accuracy of patient identification NPSG 01.01.01: Use at least 2 identifiers when

providing care, treatment, and services. Elements of performance-

Two patient identifiers are used when administering medications, blood/blood products, collecting any type of specimen for testing, providing treatments or performing procedures. The patient's room number is not one of the identifiers

Label containers used for blood and other specimens in the presence of the patient.

National Patient Safety GoalsNational Patient Safety Goals NPSG 01: Improve the accuracy of

patient identification NPSG 01.03.01: Eliminate transfusion errors related

to patient misidentification. Elements of performance-

Use a 2 person beside verification process. When using 2 person bedside verification

process, one individual conducting the identification process must be the qualified transfusionist who will administer the blood.

When using 2 person bedside verification process both individuals must be qualified to participate in the process.

National Patient Safety GoalsNational Patient Safety Goals NPSG 02: Improve the effectiveness of

communication among caregivers. NPSG .02.03.01 – Report critical results of tests

and diagnostic procedures on a timely basis. Elements of performance-

Develop written procedures for managing the critical results of tests and diagnostic procedures that address the following:

The definition of critical results of tests and diagnostic procedures. By whom and to whom critical results of tests and diagnostic procedures

are reported; The acceptable length of time between the availability and reporting of

critical results of tests and diagnostic procedures. Hospital collects data on timeliness of reporting

Implement the procedures for managing the critical results of tests and diagnostic procedures.

Evaluate the timeliness of reporting the critical results of tests and diagnostic procedures.

National Patient Safety GoalsNational Patient Safety Goals NPSG 03: Improve the safety of using medications.

NPSG 03.04.01: Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings.

Elements of performance-Label ALL medications and solutions that are not

immediately administered.Labeling occurs when any medication or solution is

transferred from the original packaging to another container.

Label must include, medication name, strength, quantity, volume, and date. If not used within 24 hours then an expiration date is needed.

Verify all medications/solutions.

NPSG 03: Improve the safety of using medications NPSG .03.05.01: Reduce the likelihood of patient harm associated

with the use of anticoagulation therapy. Elements of performance-

Use only oral unit-dose products, pre-filled syringes, or premixed infusion bags when these types of products are available.

Use approved protocols for the initiation and maintenance of anticoagulant therapy.

Before starting a patient on warfarin, assess the patient’s baseline coagulation status with INR.

Use authoritative resources to manage potential food and drug interactions for patients receiving warfarin.

When heparin is administered intravenously and continuously, use programmable pumps in order to provide consistent dosing.

Written policy addresses baseline and ongoing laboratory tests that are required for heparin and LMWH.

Education for patient/family, staff, and physicians.

National Patient Safety GoalsNational Patient Safety Goals

NPSG 07: Reduce the risk of health care-associated infections. NPSG 07.01.01: Comply with

current WHO or CDC hand hygiene guidelines. Element of performance-

Hospital complies with the current WHO or CDC hand hygiene guidelines.

Set goals for improving compliance with hand hygiene guidelines.

National Patient Safety GoalsNational Patient Safety Goals

National Patient Safety GoalsNational Patient Safety Goals NPSG 07: Reduce the risk of health care-

associated infections. NPSG 07.03.01: Implement evidence-based

practices to prevent health care-associated infections sue to multidrug-resistant organisms in acute care hospitals.

Scored starting Jan 1, 2010 Elements of performance-

Risk assessment of the hospital with education for staff and physicians about strategies to prevent MDRO at hire and annually.

Surveillance program for MDRO Policies and procedures are aimed at reducing the risk of

transmitting MDRO and are evidence-based. Hospital measures and monitors MDRO prevention

processes and outcomes.

National Patient Safety GoalsNational Patient Safety Goals NPSG 07: Reduce the risk of health care-

associated infections. NPSG 07.04.01: Implement best practices to

prevent central line-associated bloodstream infections. Scored starting Jan 1, 2010

Elements of performance-Educate staff about CLABSIs.Use checklist for insertion of central lines.

Follow ALL checklist steps.Evaluate need for central lines every day.

National Patient Safety GoalsNational Patient Safety Goals NPSG 07: Reduce the risk of health care-

associated infections. NPSG 07.05.01: Implement best practices for

preventing surgical site infections (SSI). Scored starting Jan 1, 2010

Elements of performance- Education for staff on importance of SSI prevention. All surgery patients are educated pre-operatively about

SSI prevention. Hospital clips and does not shave, if hair removal is

needed for surgery. Evidence based guidelines are used that meet

regulatory requirements such as those from the CDC.

NPSG 08: Accurately and completely reconcile medications across the continuum of care. NPSG 08.01.01: Process exists for comparing the patient’s current

medications with those ordered for the patient while under the care of the hospital. Elements of performance-

At the time the patient enters the hospital or admitted, a complete list of the medications the patient is taking at home is created and documented.

The medications ordered are compared to those on the list created at time of admission.

Any discrepancies are reconciled and documented. When the patient is transferred within the hospital the current provider

informs the receiving provider about the up to date reconciled list and documents the communication.

National Patient Safety GoalsNational Patient Safety Goals

NPSG 08: Accurately and completely reconcile medications across the continuum of care. NPSG 08.02.01: When a patient is referred to or

transferred from one hospital to another, the complete and reconciled list of medications is communicated to the next provider of care, and the communication is documented. When the next provider of care is unknown or when no formal relationship is planned with a next provider, giving the patient the list is sufficient. Elements of performance-

Patient’s most current reconciled medication list is communicated to the next provider of service.

At time of transfer, the transferring hospital informs the next provider of service how to obtain clarification on the list of reconciled medications.

National Patient Safety GoalsNational Patient Safety Goals

Medication Reconciliatio

n EPIC

***Remember- The list of discharge medications must match the list of medications in the discharge summary.***

Name and Fax Number

Remember to print and fax med

rec.

National Patient Safety GoalsNational Patient Safety Goals NPSG 08: Accurately and completely reconcile

medications across the continuum of care. NPSG 08.04.01: In settings where medications are used

minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. Elements of performance-

Hospital obtains and documents an accurate list of the patient’s current medications and known allergies.

When only short-term medications will be prescribed and no changes are made to the current medication list, the patient is provided with a list containing the short term medications that the patient will continue after leaving the hospital.

Complete reconciliation occurs if any new long term medications are prescribed.

Complete reconciliation occurs if there is a prescription change for any of the patient’s current medications.

Complete reconciliation occurs if the patient is subsequently admitted from this short term/outpatient place.

Complete reconciliation includes providing the patient/family with a copy of the reconciled list and communicating the list to the next provider of care.

National Patient Safety GoalsNational Patient Safety Goals NPSG 15: The organization identifies safety risks

inherent in its patient population. NPSG 15.01.01: The organization identifies patients at risk

for suicide. Elements of performance-

Risk assessment includes identification of specific factors and environmental features that my increase the risk for suicide.

Hospital addresses the patient’s immediate safety needs and the most appropriate setting for treatment.

Hospital provides information such as crisis hotline to individuals at risk for suicide and their family members.

Universal ProtocolUniversal Protocol

Intended to help prevent wrong-site, wrong-procedure, and wrong person surgery.

This universal protocol was required nationally for all hospitals effective in 2004.

Wrong site surgery remains a problem even after 5 years of having the Universal Protocol in place.

Organization fulfills the elements set forth in the Universal Protocol. UP 01.01.01: Conduct a pre-operative

verification process. UP 01.02.01: Mark the procedure site. UP 01.03.01: Conduct a “time-out”

immediately before starting the procedures.

Universal ProtocolUniversal Protocol

Universal ProtocolUniversal Protocol UP 01.01.01: Conduct pre procedure

verification process. Elements of performance-

Implement a preprocedure process to verify the correct procedure, for the correct patient, at the correct site.

Identify items that must be available for the procedure, and use a checklist to verify their availability.

Relevant documentation (H&P, consents, preanesthesia assessment)

Labeled diagnostic and radiology images and/or test results.

Any required blood/blood products, implants, devices, and any other special equipment.

Universal ProtocolUniversal Protocol UP 01.02.01: Mark the procedure site

Elements of performance- Identify those procedures that require marking of the

incision or insertion site. Mark the procedure site before the procedure is

performed and, if possible with the patient involved. The procedure site is marked by a licensed

independent practitioner who is ultimately accountable for the procedure and will be present when the procedure is performed.

Method of marking is unambiguous and is consistent through the facility.

A written alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site.

Universal ProtocolUniversal Protocol UP 01.03.01: A time out is performed immediately prior

to starting procedures. Elements of performance-

Conduct a time-out immediately before the procedure. The time-out contains the following characteristics-

standardized, initiated by a designated member of the team

When 2 or more procedures are being performed on the same patient, and the person performing the procedures changes, perform a time-out before each procedure is started.

Time-out includes- correct patient ID, correct site, and correct procedure.

Procedure for non-OR settings, including bedside procedures Pre-procedure verification and “time-out” procedures

should be as consistent as possible throughout the organization, this includes the bedside.

Site marking must be done

for any procedure that involves

laterality, multiple structures

or spinal levels.

Universal ProtocolUniversal Protocol

One of the most promising new surgical procedures is

performed with a felt-tip marker.

Procedure for non-OR settings, including bedside procedures Pre-procedure verification and Site-marking exception-

Cases in which the individual doing the procedure is in continuous attendance with the patient from the time of the decision to the time the procedure is conducted.

Cardiac cath lab and interventional radiology procedures are exempt, if appropriate site is assessed and accessed at the time of the procedure. (Femoral access site is assessed and access is obtained immediately after assessment of site.)

“Time-out” still applies.

Universal ProtocolUniversal Protocol

Institute of Medicine report: To Err is Human: Building A Safer Health System

Released Nov. 1999 Estimated ~98,000-100,000 people die from

medical errors alone. Estimated cost of between $17 billion and $29

billion per year in hospitals nationwide. Errors are caused by faulty systems,

processes, and conditions that lead people to make mistakes or fail to prevent them.

Medical ErrorsMedical Errors

Medical ErrorsMedical Errors

Missed diagnoses Errors during treatment

Legibility errors Patient identifiers

Medication errors Legibility issues

Mistaken identity Patient Identifiers

Medical ErrorsMedical Errors

Legibility Know that legibility is monitored and tracked by

Performance Improvement who reports it to the Best Practice committees.

Please print your name below your signature. ALWAYS include the last 4-digits of your pager

number (Residents only). Other providers must leave a contact number either

a phone number or pager number.

Example of poor handwriting- physician.

Example of poor (not horrible, but not great) nurse’s handwriting here at UT Southwestern University Hospitals

Medication errors Cost ~2 billion dollars/year. Increases LOS by average of 4 days. Adds ~ $8750 to each hospital bill.

Medical ErrorsMedical Errors

The above script was misinterpreted by 106 out of 158 physicians, roughly 67%.The pharmacist misinterpreted it also.The patient was given Plendil 20mg and took it as per the script, which is 8 times the usual and safe dose of Plendil per day.After three days the patient was admitted to a hospital with severe heart failure and subsequently died 2 weeks later.The intended prescription was for Isordil 20mg PO Q6 hours.

What would you do as the RN or the Unit Secretary if you received this order? How would you interpret it?

Intended script- Z-Pack as directed

Interpreted as Levaquin 500mg PO BID

Intended script-Paregoric 5cc PO BID for 1 month

Two more examples of Two more examples of prescriptionsprescriptions Again what would

you do if these were written in the orders? How would you interpret them?

For more information:For more information:

The Joint Commission websiteThe Joint Commission website

www.jointcommission.orgwww.jointcommission.org

How to contact the Joint CommissionHow to contact the Joint Commission

1-800-994-66101-800-994-6610

RememberRemember

Think Think

Patient SafetyPatient Safety

First !First !