Transcript NQF 34 SAFE PRACTICES 2011 PT 1 OF 2

NQF 34 Patient Safety
Practices for Hospitals 2011
Part 1 of 2
Speaker
 Sue Dill Calloway RN, Esq.
CPHRM
 AD, BA, BSN, MSN, JD
 Medical Legal consultant
 5447 Fawnbrook Lane
 Dublin, Ohio 43017
 [email protected]
 614 791-1468
2
NQF 34 SAFE PRACTICES
 Released in 2003, updated 2006, 2009 and April 2010
 These should be followed in all healthcare facilities
including:
 All clinical care settings to reduce risk of harm to patients
especially hospitals
 A roadmap to preventing harm
 Have you done a gap analysis to see where your facility is
at?
 States 10 years after IOM report, To Err Is Human, uniformly
reliably safety in healthcare has not been achieved
 Several resources dovetail this publication
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Patient Safety Primer
AHRQ has a patient safety primer that is
designed to help users to understand key
concepts in patient safety
 It has a section on handoffs and sign-out’s,
healthcare associated infections, and adverse
event after discharge
 Never events, CPOE, medication reconciliation,
disclosure, root cause analysis and rapid
response systems
 http://psnet.ahrq.gov/primerHome.aspx
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Patient Safety Handbook for Nurses
 AHRQ has a free evidenced based handbook for
nurses
 Dove tails NQF 34 Safe Practices well
 1,400 pages and 51 separate chapters
 Can print off, order the 3 volume set, or a CD
 Includes chapters on many great topics such as
defining patient safety, staffing, medications errors,
patient centered care, falls, patient safety
opportunities, handoffs, disclosure, communication,
HAI, wrong site surgery, etc.,
 At http://www.ahrq.gov/qual/nurseshdbk/
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Formats for Collecting Patient Safety Information
 AHRQ and Dept of HHS have published common
formats for collecting and reporting patient safety
information, working with NQF,
 Formats authorized by Patient Safety and Quality
Improvement Act of 2005 (PSO),
 Resource contains common definitions,
 Includes reporting format for facilities to collect and
track patient safety information in same manner,
 available at http://www.pso.ahrq.gov
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2010 Updated Forward NQF 34 Safe Practices
 This includes failure of an effective reporting
system
 Includes failure to learn from errors within a blamefree culture
 Updated with current evidenced based
 Systematic and universal implementation of these
practices can lead to appreciable and sustainable
improvements for healthcare safety
 Manual includes latest safety evidence,
implementation strategies, and guidance
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Did You Know?
 Preventable medical errors are actually on the rise
by 1% per year
 There are about 1.7 million HAIs and 99,000 deaths
a year
 There are at least 1.5 million preventable drug
events each year due to drug mix ups and
unintentional over doses
 18 types of medical errors account for 2.4 million
extra hospital days and $9.3 billion in excess care
 Source:Sorra J, Famolaro T, et al. Hospital Survey on Patient Safety Culture 2008 Comparative
Database Report. AHRQ Publication No. 08-0039. Rockville, MD: Agency for Healthcare Research and
Quality, 2008
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Did You Know?
 One in five patients discharged from the hospital
end up sicker within 30 days and half are
medication related
 One of 10 inpatients suffers as a result of a
mistake with medications which causes significant
injury or death
 Preventable medical errors cost the US $17 to $29
billion dollars a year
 Source: Safe Practices for Better Healthcare Why Implement Practices to Improve Safety at
http://www.qualityforum.org/News_And_Resources/Press_Kits/Safe_Practices_for_Better_Healthcare.
aspx
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2010 Safe Practices
 34 Safe Practices for Better Healthcare
 Organized into 7 functional categories
 Leaders and boards are called upon to proactively
review the safety of their organization and to take
action to improve safety
 Detailed bib list in book at end
 Evidenced based and excellent resources
 Also has list of 28 never events or serious
reportable errors that many states require to be
reported
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NQF Other Publications
 NQF also has a document on assessment and
prevention of healthcare-associated infections
(HAI),
 Endorsed a set of Patient Safety Indicators
developed by AHRQ (Agency for Healthcare
Research and Quality,
 www.ahrq.gov
 Additional safety related work include;
 Prevention of venous thromboembolism (DVT)
 Pressure ulcer prevention, perioperative care
 Safety and medication management measures
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AHRQ Patient Safety Indicators
www.qualityindicat
ors.ahrq.gov/psi_o
verview.htm
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How to Order the Book
 Can be ordered at National Quality Forum at
www.qualityforum.org or
www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_–_2010_Update.aspx
 No cost for members
 Non-member copy is $29.99 to download off
website
 Print copy is $89.99
 Safe Practice for Better Healthcare-2010 Update: A
Consensus Report
 Call 202 783-1300
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2010 Resources
 List of Safe Practices to show 2010 changes and
new resources (48 pages)
 http://qualityforum.org/News_And_Resources/Press_Kits/S
afe_Practices_for_Better_Healthcare.aspx
 Free 11 page summary report
 Press release for 2010 report
 Free webinars at Texas Medial Institute of
Technology (TMIT) at www.safetyleaders.org/home.jsp
 Also watch the Dennis Quade Patient Safety Video called
Chasing Zero
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Patient Safety Video
http://www.safetyleaders.org/pages/chasingZeroDocumentary.jsp
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Resources on Safe Practices
 NQF, publication unit, 601 Thirteenth Street, NW,
Suite 500 North, Washington, DC, 2005
 www.qualityforum.org
 TMIT has a website at safetyleaders.org
 Does free monthly programs on these at
http://www.tmit1.org/pages/workshopsWebinars.jsp
 Can listen to past presentations
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TMIT Monthly Webinars
http://www.safetyleaders.org/pages/workshopsWebinars.jsp?step=2
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34 Practices Divided into 7 Chapters
2.
Creating and sustaining a culture of safety
3.
Informed consent, life sustaining treatment, care of
caregiver, and disclosure
4.
Matching healthcare needs with service delivery
capability
5.
Facilitating information management and clear
communication
6.
Medication management
7.
Prevention of healthcare-associated infections
8.
Condition and site specific practices,
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2010 NQF Report
Culture
Consent & Disclosure
Consent & Disclosure
Workforce
Information Management &
Continuity of Care
Medication Management
Healthcare-Assoc. Infections
Condition- &
Site-Specific Practices
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2010 NQF Report
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Culture
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
Structures
& Systems
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
ID Mitigation
Risk & Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
Disclosure
Workforce
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Information Management & Continuity of Care
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CPOE
Abbreviations
Medication Management
•
Med. Recon.
Pharmacist
Central Role
High-Alert
Meds.
Std. Med.
Labeling & Pkg.
Unit-Dose
Medications
Healthcare-Associated Infections
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath.
BSI Prevention
Sx Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
•
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
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Culture
2010Culture
NQFSPReport
1
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
CHAPTER 2: Creating and Sustaining a Culture of Patient Safety
• Leadership Structures & Systems (Safe Practice 1)
Consent&&Disclosure
Disclosure
• Culture Measurement, Consent
Feedback
and Interventions(Safe Practice 2)
• Teamwork Training and Team Interventions (Safe Practice 3)
• Identification and Mitigation of Risks and Hazards (Safe Practice 4)
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas,
F.B, & Interv.
Informed
Consent
Life Sustaining
Treatment
ID Mitigation
Risk & Hazards
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life Sustaining Treatment
• Disclosure
Disclosure
Work Force
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
ICU Care
Information Management & Continuity of Care
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
CPOE
Abbreviations
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Medication Management
•
Med. Recon.
Pharmacist
Central Role
High-Alert
Meds.
Std. Med.
Labeling & Pkg.
Unit-Dose
Medications
Hospital-Associated Infections
•
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
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• Contrast Media-Induced Renal Failure Prevention
1. Leadership Structures and Systems
 Leadership structures and systems must be
established to ensure that there is organizationwide awareness of patient safety performance
gaps,
 Direct accountability of leaders for those gaps,
 Adequate investment in performance improvement
abilities,
 Actions must be taken to ensure safe care of every
patient served.
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1. Leadership Structures and Systems
 Do you have a patient safety program?
 Is there education on patient safety and patient safety
plan?
 Just culture where frontline staff are comfortable
disclosing errors but still maintains accountability?
 Is there a patient safety officer?
 Who coordinates patient safety education?
 With direct and regular communication with board and
senior leaders?
 Senior leaders and department directors are accountable
to close performance gaps
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1. Leadership Structures and Systems
 Is there an interdisciplinary patient safety
committee?
 Do leaders support the committee?
 Board and leaders help set patient safety goals
 Oversee RCA and feedback to frontline workers
 Provides training in teamwork techniques
 Direct organization-wide leadership accountability
 Board briefed in results of culture survey and
activities to identify and mitigate risks
 Every board meeting should include patient safety issues
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1. Leadership Structures and Systems
 Direct patient input on formal committees on safety
and not just patient satisfaction surveys
 Board and senior leadership should regularly
assess budgets for patient safety, people systems
(staffing), PI, and technology that impact safety
 Board members should be trained in team work
(discussed later) and patient safety
 Board should be competent in patient safety and do an
annual assessment and ensure new board members well
versed in patient safety
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http://teamstepps.ahrq.gov/index.htm
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1. Leadership Structures and Systems
 Board and senior LD and CEO need to establish
systems to ensure medical leaders have input into
safety programs
 CEO and senior leadership should design certain
amount of time for patient safety activities
 Teamwork training
 Take actions to identify and mitigate risks and hazards
(discussed in detail later)
 Regular patient safety related session at meetings
 Weekly walk-rounds
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Patient Safety Walk Abouts
Also called leadership walk rounds or
executive walk rounds
AHA has easy to use manual developed in
conjunction with 3 year pilot program in 10
hospitals
200 hospitals used thru IHI collaboration
Research shows positive effect on safety
culture attitudes of nurses and improves
safety culture
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AHA Opening Statement
We are moving as an organization to open communication
and a blame-free environment because we believe that by
doing so we can make your work environment safer for you
and your patients. The discussion we are interested in
having with you is confidential and purely for patient safety
and improvement.
We are interested in focusing on the systems you work in
each day rather than on blaming specific individuals. The
questions we might ask you will tend to be general ones,
and you might consider how these questions might apply in
your work areas in regards medication errors,
communication or teamwork problems, distractions,
inefficiencies, problems with protocols etc.
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AHA Opening Statement
We are happy to discuss any
issues of concern to you. Our
goal is to take what we learn
in these conversations and
use them to improve your
work environment and the
overall delivery of care.”
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Questions Asked in Walk Rounds
Have there been any near misses that almost
caused patient harm today?
Have we harmed any patients recently?
What aspects of the environment are likely to
lead to harm?
Is there anything we could do to prevent the
next adverse event?
 http://www.wsha.org/files/82/WalkRounds1.pdf and
http://www.hret.org/hret/programs/protemp.html
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Questions Asked in Walk Rounds
Can you think of any events in the past days
which have resulted in prolonged
hospitalization for a patient?
Can you think of a way in which the system
or your environment fails you on a continual
basis?
Would specific interventions from leadership
could make your work safer?
What would make this executive walkabout
more effective?
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Patient Safety Walk Rounds IHI ihi.org
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Patient Safety Walk Rounds AHA
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2. Culture Measurement, Feedback, & Intervention
Hospitals must measure their culture,
Provide feedback to the leadership
and staff,
Hospitals must undertake
interventions that will reduce patient
safety risk
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Definition of Patient Safety
Definition of Patient Safety by NQF;
Freedom from injury or illness resulting from
the processes of care,
Patient safety event is an occurrence or
potential occurrence, that is directly linked to
the delivery of healthcare that results, or
could result, in injury, death, or illness,
AHRQ Survey Tool
 Need to measure culture and provide feedback at
least on yearly basis
 Patient Safety Culture Survey website
 at www.ahrq.gov/qual/patientsafetyculture/
 Has a hospital survey on patient safety culture
 TJC LD.03.01.01 requirement
 EP 1: Leaders regularly evaluate the culture of
safety and quality using valid and reliable tools
 Many similar TJC leadership standards
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AHRQ Survey Tool
 AHRQ survey tool you can compare your data to
other hospitals
 Hospital survey toolkit and comparative database
report available, survey user’s guide, survey items
and domains, feedback templates, assistance
briefings, etc.,
 AHRQ has tool for hospitals, nursing homes and
physician offices
 Domains include teamwork, communication, PI,
leadership and openness to reporting
 Disseminate results
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Hospital Survey AHRQ
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44
Patient Safety Culture Questions
 Communication and frequency of events reported
section
 Staff will speak up if they see something that may
negatively affect patient care
 Staff feel free to question the decisions of those with
more authority
 Do staff feel like their mistakes are held against
them?
 Do staff worry that mistakes they make are kept in
their personnel file?
45
Patient Safety Culture Questions
 Staff are afraid to ask questions when something
does not seem right
 Is mistake caught still reported (TJC and CMS
require reporting of near misses)
 Problems often occur in the exchange of
information
 Staff feel there are patient safety problems on the
unit?
 See safety toolkits for leaders at
www.mnhospitals.org/index/toolkits
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47
48
3. Teamwork Training & Skill Building
 Healthcare organizations must establish a
proactive, systematic, organization-wide approach
 to developing team-based care through teamwork
training,
 skill building,
 and team-led performance improvement
interventions that reduce preventable harm to
patients.
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3. Team Work
 Every hospital should have team work and
communication training (time out before surgery,
huddles, SBAR, hand-offs) and at all levels
 Start with staff in areas with high risk (ICU, ED, Perinatal)
 Should include hand-offs, communication failures,
team failures that lead to patient harm
 Should include high reliability principles, human
factors, and interpersonal team dynamics
 Good place to get resources on these topics is
AHRQ PSNet at http://www.psnet.ahrq.gov/
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3. Team Work
 Should include effective skill building such as stop
the line method
 Should document team training
 Identify every year number of teamwork-centered
intervention projects such as specific team PI
projects (ED, L&D, OR, ambulatory, ICU), rapid
response assessment (RRT),
 Crew Resource Management (CRM) and AHRQ
TeamSTEPPS are two examples
 CRM used in airline safety and originated from NASA to
prevent human error
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http://teamstepps.ahrq.gov/index.htm
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4. Identification & Mitigation of Risks& Hazards
Healthcare organizations must
systematically identify and mitigate
patient safety risks and hazards
 with an integrated approach
 in order to continuously drive down
preventable patient harm
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4. Identification & Mitigation of Risks& Hazards
 Need to identify risks and hazards on an ongoing
basis
 Need to include information gained from multiple
sources
 Culture should focus on system and not individuals
(system analysis theory)
 Including blame free reporting to create a just
culture
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Chasing Zero: Winning the War on Healthcare Harm
http://link.brightcove.com/services/player/bcpid79301804001
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Videos You Should Watch Share Rounds
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The Power of a Story Jossie King
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4. Identification & Mitigation of Risks& Hazards
 Annual report should be done on progress on
evaluation of activities and tools used
 Serious reportable events (NQF lists 28)
 Sentinel event reporting (TJC has a list of
reviewable sentinel events)
 Adverse event reporting, RCA done
 Closed claims analysis, skill mix
 Patient safety indicators (AHRQ has)
 Trigger tools (IHI has 9)
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4. AHRQ Patient Safety Indicators
 These are a tool to help leaders identify potential
adverse events during hospitalization
 Identify complication following surgeries,
procedures, and childbirth
 PSIs is a software tool from AHRQ to help identify
AE that need further study
 Developed by Stanford University and University
of California under contract with AHRQ
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AHRQ Patient Safety Indicators
www.qualityindicators.ahrq.gov/psi_overview.htm
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IHI Trigger Tools
www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IntrotoTriggerToolsforIdentifyingAEs.htm
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4. FMEA or PRA
 Hospitals should do one proactive risk assessment
per year
 FMEA or failure mode and effect analysis
 PRA or probablistic risk assessment (looks at risk by
severity or likelihood of occurrence and what could go
wrong and uses fault tree analysis)
 TJC in LD.04.04.05 also requires
 EP6. The hospital defines responses to various types of
potential AE. There needs to be a system approach for
blame free reporting of a system or process failure. This
also included the results of the proactive risk assessment
(FMEA),
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Sample FMEA Anticoagulant ISMP
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4. Organization Wide Risk Management
 Look at risks and hazards across the organization
to identify patterns, system failures and contributing
patterns
 Risk management and claims management
 Complaints and customer service participation
 Culture measurement and intervention
 Disclosure support system
 Anticipated risk for surge in capacity as for flu
pandemic or disaster
69
4. PI Program
 PI program to close patient safety gaps
 Need targeted PI projects aimed at patient
safety
 Need products and technologies for quality and
patient safety (bar coding, smart pumps,
automated dispensing unit)
 Use dashboards or scorecard to document
progress of all patient safety programs
70
4. Risk Assessment and Mitigation
 Document following high risk areas and actions
takes to close patient safety gaps
 Falls and effectiveness of fall reduction program
 Malnutrition
 Pneumatic tourniquets and evaluate for risk of
ischemia and or thrombotic complications
 Aspiration assessment upon admission
 Workforce fatigue (Pa Patient Safety Authority
has toolkit at
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/aspiration/Pages/home.aspx
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PA Patient Safety Authority
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Culture
2010Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
CHAPTERS 2-8 :
Practices By Subject
Life Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
CHAPTER 3: Informed Consent & Disclosure
• Informed
Consent (Safe Practice 5)
Work Force
• Life-Sustaining Treatment (End of Life, Safe Practice 6)
• Disclosure (Safe Practice 7)
• CareManagement
of the Caregiver
Information
& Continuity of(Safe
Care Practice 8)
Nursing
Workforce
Direct
Caregivers
Critical
Care Info.
Labeling
Studies
Disclosure
ICU Care
Order
Read-back
Discharge
System
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
CPOE
Abbreviations
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Medication Management
•
Med. Recon.
Pharmacist
Central Role
High-Alert
Meds
Std. Med.
Labeling & Pkg.
Unit-Dose
Medications
Hospital-Associated Infections
•
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
74
• Contrast Media-Induced Renal Failure Prevention
NQF Safe Practices Informed Consent
 Ask each patient or
legal surrogate to "teach
back" key information
about proposed
treatments or
procedures for which he
or she is asked to
provide informed
consent
75
5. Informed Consent
 Patient should be able to explain in everyday words
their diagnosis or health problem for which they
need care
 CMS Hospital CoP Patient Right for patient to know their
diagnosis and prognosis
 Patient should know the name of the treatment or
procedure
 This includes risks, benefits, and alternatives
 CMS has 3 sections in hospital CoP on informed
consent including 6 mandatory elements
 Consent is a process and not a form
76
5. Informed Consent
 Remember to include your state law on consent
 TJC RI.01.03.01 has consent standard with 13 EPs
 TJC 2011 patient-provider communication standards
 Informed consent documents written at 5th grade
level
 Remember low health literacy issue
 Interpreter used if does not speak English
 Please tell me in your own words what you surgery
you are having done
 Minnesota project to get consent to be understandable
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www.mnpatientsafety.org/index.php?option=com_conten
t&task=view&id=85&Itemid=69
78
79
Ask Me 3 Website
80
Informed Consent Summary
 Know your policy and procedure
 Document consent in medical record
 Make sure on chart before they go to surgery
 Know state law, TJC standards, CMS hospital CoPs,
AOA HCAP standard, DNV NIAHO (National
Integrated Accreditation for Healthcare
Organizations) or whatever standard applies to your
facility
 Policy states when surrogate decision makes may
give informed consent such as guardian or DPOA
81
NQF Safe Practices Life Sustaining Treatment
 Ensure that written
documentation of the
patient's preferences for lifesustaining treatments is
prominently displayed in his
or her chart,
82
6. Life Sustaining Treatment
 Have a process in place to determine what
preference patient has and document
 Prominently display in chart
 Know what advance directives the patient has
 Document their wishes
 DNR, DPOA, Organ donor, Living will, Mental
health declaration
 Have sticker on front of chart
 TJC standard to have way to communicate to other
departments (The Joint Commission, no longer JCAHO)
83
6. Life Sustaining Treatment
Document on admission if patient wants to
make any changes (TJC standard also),
Give written copy of patient rights (CMS
requirement)
Facility helps patient formulate advance
directives
P&P to the extent hospital will honor them
Have copies on the chart of ADs
84
6. Life Sustaining Treatment
 Refer patient or assist in formulating advance
directives (TJC and CMS)
 Adults are given information on their right to refuse
care (TJC and CMS requirement)
 Be aware of how spiritual beliefs affect their view of
end of life care
 Physicians and caregivers need education on how
compassion fatigue and self awareness to minimize
burnout
85
NQF Safe Practices 7 Disclosure
 Following serious,
unanticipated outcomes,
the patient and, as
appropriate, family should
receive communication
about the event,
 Called disclosure of
unanticipated outcomes
86
7. Disclosure of Unanticipated Outcomes (UO)
 At a minimum must include sentinel events (TJC),
serious reportable events (NQF), and any UO
involving harm such as increased LOS (length of
stay), additional care such as a test or procedure,
loss of limb or function lasting 7 days or longer
 Need P&P
 Need a formal process for disclosing
 Provide all LIPs with detailed description of program
including full disclosure
 Document in the medical record (also TJC standard
RC.02.01.05 EP1)
87
7. Disclosure
 Leadership needs to make sure information is used
for performance improvement
 Adherence should be part of credentialing
 Includes what information should be communicated
to patient such as the facts, empathic
communication, commitment to investigate and
provide to patient safety leaders, results of
investigations, timeliness, an apology
 Emotional support for patients by trained caregivers
 Emotional support for caregivers
88
7. Disclosure
 Consider a disclosure coach
 Consider providing information to a PSO
 Process in place for early remediation and waiving
of billing and for subsequent treatment if system or
human failure
 TJC standard , NPSF statement, and AMA Code
of Ethics on this
 RI.01.02.01 EP21 Patient or surrogate decision maker is
informed about outcomes of care and treatment in order
to participate in current and future healthcare decisions
89
TJC Disclosure Standard
EP22 LIP responsible for managing patient’s
care, or their designee, informs the patient
about the unanticipated outcomes (UO)
related to SE when patient is not aware of the
occurrence or where further discussion is
needed
90
National Patient Safety Foundation
 “Talking to patients about Health Care Injury.”
 Available at http://www.npsf.org
 When a health care injury occurs, the patient and the family
or representative is entitled to a prompt explanation of how
the injury occurred and its short and long-term effects. When
an error contributed to the injury, the patient and the family or
representative should receive a truthful and
compassionate explanation about the error and the
remedies available to the patient.
 They should be informed that the factors involved in the
injury will be investigated so that steps can be taken to
reduce the likelihood of similar injury to other patients.
91
ASHRM 4 Documents on UO
20 page document titled “Perspective on disclosure of
unanticipated outcome information”
Provides examples of UO Policy and procedures
Has additional 3 documents, Disclosure: What works now
and what can work even better,
Disclosure: Creating an effective patient communication
policy, and.
Disclosure: the next step in better communications with
patients,
At http://www.ashrm.org/ashrm/resources/monograph.html
92
Who Needs What and When?
Need
A=Physician need to disclose
B=Patient need to hear
A
B
Time
93
AMA Code of Medical Ethics Section 8.12
States physician has ethical duty to deal
honestly and openly with patient at all times
 Patients have right to know their past and
present medical condition
and to be free of any mistaken beliefs
 This includes all facts necessary to
understand what has occurred-regardless
of legal liability that might result
Unanticipated Outcomes
Often patients just want to know changes
will be made so will not happen to someone
else
They want to know change will be made
Some facilities offer upfront compensation
Many recent articles to show physicians are
not doing this right
In reality this is much more complicated
than it looks
Sorry Works
 Consider “sorry works” initiative
 Adopted by a large number of hospitals throughout
the country
 To reduce lawsuits
 Believe that apologies and upfront compensation for
medical errors reduces lawsuits and liability costs
 Need to have a successful disclosure program.
 Go to www.sorryworks.net
 See also Canadian Disclosure Guidelines at
www.patientsafetyinstitute.ca
96
Sorry Works
 Supported by studies done at Lexington VA
hospitals/all VA hospitals and
 University of Michigan/Stanford University and
Harvard Teaching Hospitals and many others
 Stay in close contact with patient/family and return
all phone calls promptly and pleasantly
 Remember RCA
 Apology for what happened and explained what
happened and how you fixed it
 Should always check with your malpractice carrier
97
NQF Safe Practice 8 Care of the Caregiver
 Following serious unintentional harm due to
systems failures and/or errors
 That resulted from human performance failures
 The involved caregivers (clinical providers, staff,
and administrators) should receive timely and
systematic care to include:
 Treatment that is just, respect, compassion,
supportive medical care, and the opportunity to
fully participate in event investigation and risk
identification and mitigation activities that will
prevent future events
98
8. Care of the Caregiver
 Caregivers includes all providers and staff involved
in adverse events
 An OB nurse works a double and stays at the
hospital to get a few hours of sleep before she
starts the day shift
 A 16 year old comes in and she has the IV antibiotic
and IV for the Epidural infusion in her hand
 She administers the wrong one and the patient dies
 She loses her license, her job, and is criminally
charged
99
8. Care of the Caregiver
 IV tubings look alike, no bar coding, fatigued
healthcare worker, no double checks
 Was this fair and just?
 Lead to the development of this chapter
 Harm can occur to caregivers
 depression, anxiety, sleeping difficulties etc.
 If not managed correctly harm can occur to the
culture of the organization
 Process to provide information to a PSO that
protects confidential information
100
8. Care of the Caregiver
 Need evidenced based process to assess behavior
of those involved with an AE to identify if substance
abuse, intentional harm, reckless disregard of clear
P&P (Just Culture Theory)
 If system failure or predictable human performance factor
then clear from direct personal blame within 24 hours
 If contemplating a corrective action that could result
in serious loss of livelihood the person should be
notified and give opportunity to seek legal counsel
before providing a formal statement
101
8. Care of the Caregiver
 Designated leaders should be trained in the critical
importance of forgiveness and process to have coworkers express understanding and compassion
 Supportive care for the caregiver in serious
unintentional harm and opportunity to receive
professional help (Employee Assistance Programs)
 Just in time coaching to leaders who are involved
with this process with formal system to educate
senior leaders, staff and caregiver
102
Culture
2010Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Team Training
& Team Interv.
Culture Meas,
F.B, & Interv.
Structures
& Systems
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
CHAPTERS 2-8 :
Practices By Subject
Life Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life Sustaining Treatment
• Disclosure
CHAPTER 4: Workforce
• Nursing
Workforce (Safe Practices 9)
Work Force
• Direct Caregivers (Safe Practices 10)
• ICU Care (Safe Practices 11)
Nursing
Workforce
Disclosure
Direct
Caregivers
ICU Care
Information Management & Continuity of Care
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
CPOE
Abbreviations
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems including
CPOE
• Abbreviations
Medication Management
•
Med Recon.
Pharmacist
Central Role
High Alert
Meds
Std. Med
Labeling & Pkg
Unit Dose
Medications
Hospital Associated Infections
•
Asp +VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition & Site Specific Practices
Evidence
Based Ref.
Press. Ulcer
Prevention
Anticoag
Therapy
Wrong site
Sx Prevention
Peri-Op MI
Prevention
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit Dose Medications
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and Ventilator
Associated Pneumonia,
Central Venous Catheter Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Peri-operative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
103
• Contrast Media-Induced Renal Failure Prevention
NQF Safe Practices 9
 Implement critical components of a
well designed nursing workforce,
 That mutually reinforce patient
safeguards, including the following
 A nurse staffing plan with
evidence that it is adequately
resourced and actively managed
and that its effectiveness is
regularly evaluated with respect to
patient safety.
104
NQF Safe Practices 9
 Senior administrative nursing leaders, such as a
Chief Nursing Officer, is part of the hospital senior
management team (TJC standard)
 Boards and senior administrative leaders that take
accountability for reducing patient safety risks
related to nurse staffing decisions and the provision
of financial resources for nursing services
 Provision of budgetary resources to support nursing
staff in the ongoing acquisition and maintenance of
professional knowledge and skills.
105
9. Nursing Workforce
 P&P, with input from nurses, on effective staffing
that specify number, competency, and skill mix of
nursing staff
 Ensure board, senior and mid management are
educated on impact of staffing on safety
 Conduct risk assessments related to nurse staffing,
work hours and temporary coverage
 Use data to monitor staff level (sensitive nursing
indicators such as more falls, medication errors,
longer LOS, codes, GI bleeds, UTIs, etc.
106
Nursing Linked to Safety
 Adequate staffing levels linked to safety
 Limits number of hours worked to prevent fatigue
 38% more likely to make an error if work over 12
hours
 No mandatory overtime
 There are three major studies
 Redesigning the work force, See Keeping Patients Safe:
Transforming the Work Environment of Nurses 2004, IOM
at www.nap.edu/openbook/0309090679/html/23/html, see
multiple studies pg 227-239,
Nursing Linked to Safety
 March 2007, Nursing Staffing and Quality of
Patient Care, AHRQ Pub No. 07-E005, Minnesota
Evidenced Based Practice Center, at
http://www.ahrq.gov/downloads/pub/evidence/pdf/
nursestaff/nursestaff.pdf
 Patient Safety and Quality An Evidenced Based
Handbook for Nurses, AHRQ Publication No.080043, 2008, Chapter 25 Nurse Staffing and
Patient Care Quality and Safety at
http://www.ahrq.gov/qual/nurseshdbk/
9. Nursing Workforce
 Ongoing assessment to make sure
nurses are oriented and competent
to provide safe care
 Including float nurses, contract
staff and agency nurses
 Matching healthcare needs with
service delivery capability to
improve patient safety
109
Safe Practice 10 Direct Caregivers
Ensure that non-nursing direct
care staffing levels are
adequate,
That the staff are competent,
That they have had adequate
orientation, training, and
education to perform their
assigned direct care duties
110
10 Direct Non-Nursing Caregivers
 Establish a staffing plan that is adequately
resourced and managed
 Do risk assessment to identify patient safety risks
related to non-nursing direct care workers including
work hours and staffing
 Ensure resources for PI program based on risk
assessment
 Have P&P to meet staffing targets to include
number, competency and skill mix
111
Safe Practice 11 ICU Care
All patients in general
intensive care units (both
adult and pediatric)
Should be managed by
physicians who have
specific training and
certification in critical care
medicine (“critical care
certified”)
112
11 ICU Care
 Dedicated critical care certified physicians should
be present in the ICU during daytime hours
 8 hours a day and seven days a week
 If unable to have 8 hours then round the clock
eICU monitored by critical care physician
 If critical care physician not present then physician
shall provide telephone coverage
 Must return 95% of ICU pages within 5 minutes
113
Critical Care Patients
 Make sure the critically ill have appropriately skilled
caregivers in the ICU
 Studies show errors are common in the ICU
 20% of all ICU patients have serious adverse event
 Higher mortality rate if you do not have a physician
trained and certified in critical care medicine
 See book on Critical Care Safety: Essentials for
ICU Patient Care and Technology by ECRI
 610 825-6000 or www.ecri.org,
114
Culture
2010Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
Disclosure
CHAPTER 5: Information Management & Continuity of Care
Workforce
CHAPTERS 2-8 :
•
Patient
Care
Information
(Safe Practice 12)
Practices By Subject
• Order Read-Back and Abbreviations (Safe Practice 13)
• Labeling and Diagnostic Studies (Safe Practice 14)
Information Management & Continuity of Care
• Discharge
Systems (Safe Practice 15)
• CPOE (Safe Practice 16)
•
Nursing
Workforce
Direct
Caregivers
Critical
Care Info.
Labeling
Studies
ICU Care
Order
Read-back
Discharge
System
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
CPOE
Abbreviations
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
Medication Management
•
Med Recon.
Pharmacist
Central Role
High Alert
Meds
Std. Med
Labeling & Pkg
Unit Dose
Medications
Hospital-Associated Infections
•
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
115
• Contrast Media-Induced Renal Failure Prevention
NQF Safe Practices 12
Ensure that care information is
transmitted and documented in
a timely and clearly
understandable form to patients
and patient's healthcare
providers within and between
care settings.
Recall that 70% of all errors are
due to communication failures,
116
12 Patient Care Information
 Identify communication gaps about critical test
results and include in PI
 Implement process that critical results are
communicated quickly to the LIP
 Values defined as critical by the lab must be reported in
specified timeframes
 Have process to report critical test results to
alternative practitioner if patient’s LIP is not
available
 Ensure patients have access to their MR within 24
hours of written request (not 30 days as in HIPAA)
117
TJC 2011 NPSG 2: Critical Results of Tests
NPSG.02.03.01 Report critical results of tests and
diagnostic procedures on a timely basis
EP 1 Develop procedures for managing the critical
results of tests and diagnostic procedures that
address the following;
 Definition of critical test results and diagnostic
procedures
 By who and to whom critical results are reported
 Acceptable length of time between availability of results
and calling
118
119
TJC Goal 2: Critical Test Results
 EP 2 Implement the procedure for managing
critical results of tests and diagnostic procedures
 EP3 Evaluate the timeliness of reporting critical test
results and diagnostic procedure results
 Term “critical tests” has been removed and now talks
about critical results
 Critical results are tests and diagnostic procedures which
fall significantly outside the normal range and could
indicate a life threatening situation
 Want to be sure patient is promptly treated so let
doctor know blood sugar is 760
120
NQF 13 Order Read Back & Abbreviations
 Incorporate within your organization a
safe, effective communication strategy,
structures, and systems to include the
following:
 For verbal or telephone orders or for
telephonic reporting of critical test
results, verify the complete order or
test result by having the person who is
receiving the information record and
“read-back” the complete order or test
result
 TJC PC.02.01.03 and CMS CoPs also
require this
121
NQF 13 Order Read Back & Abbreviations
Standardize a list of “Do Not
Use” abbreviations, acronyms,
symbols, and dose designations
that cannot be used throughout
the organization
TJC had 9 do not use
abbreviations and moved in
2010 from NPSG to IM.02.02.01
which continues in 2011
122
TJC Information Management IM.02.02.01
EP3 The policy must be implemented
regarding the terminology, definitions,
abbreviations, acronyms, symbols, and
dose designations permitted for use in the
hospital
And the do not use abbreviations,
acronyms, symbols, and doses
123
NQF 13 Order Read Back & Abbreviations
 Do not use verbal orders unless impossible for
practitioner to write the order
 CMS 407, 408, 454, & 457 and TJC standard also
PC.02.03.07 and RC.02.03.07
 Need P&P to minimize the use of verbal orders
 Write it down or enter it into the computer and
repeat it back
 Receive confirmation back
 Prohibit u, IU, qd, qod, trailing zero, absence of
leading zero, MS, MSO4 or MgSO4
124
Dangerous Abbreviations
 Institute for Safe Medication Practices (ISMP) has
published a list of dangerous abbreviations relating
to medication use
 Post copies in nursing station and give copy to all
physicians
 Go to www.ismp.org or
http://www.ismp.org/PDF/ErrorProne.pdf
 Trailing zero is prohibited only for medication
related notations-okay for lab such as K+ is 4.0 or
ET tube is 7.0
126
Labeling of Diagnostic Studies Safe Practice 14
 Implement standardized policies,
processes, and systems
 To ensure accurate labeling of
radiographs, laboratory
specimens, or other diagnostic
studies,
 So that the right study is labeled
for the right patient at the right
time
127
14. Labeling of Diagnostic Studies
 Label lab specimen containers at time of use in the
presence of the patient
 Also a TJC requirement NPSG.01.01.01
 Match the patient to the intended service or
treatment using two identifiers
 Can not be floor or room number
 When taking blood or other specimens and for treatments
 Label x-ray imaging studies with correct information
while in the darkroom or close to the imaging device
128
TJC Goal 1:Improve the accuracy of patient identification.
Recommendations: Use at least two patient
identifiers when providing care, treatment or
services.
1. Use two identifiers in administering meds or
hanging blood or blood products, when collecting
blood samples or other specimens for clinical
testing and (EP 2),
– Reference to what to do before starting a blood transfusion under
NPSG.01.03.01 EP1
2. Must label blood and other specimens in presence
of patient (no batching or prelabeling the vials,
EP 6),
129
14. Labeling of Diagnostic Studies
 Make right or left on images to prevent
misinterpretation at the light box
 Monitor and report errors and harm related to
mislabeling
 In surgery, debriefing can help prevent this
 There are many studies to show the high
number of specimens that are labeled
incorrectly or have errors
 Include as part of PI project
130
www.scoap.org
131
132
133
Labeling of Specimens
 2007 study looked at 21,000 surgical specimens, 91
errors,
 Error rate was 4.3 per 1000 specimen,
 Error rates higher for specimens associated with a
biopsy procedure and in the outpatient setting,
 Specimen mislabeling was one kind of error,
 TJC addresses specimen labeling in the NPSGs,
 Found surgical specimen identification errors are
common and pose risk to patients,
 Strategies to reduce this risk should be research priority,
 Surgery, 2007, April, Makary MA,
134
Labeling of Specimens
 Study found;
 18 specimens not labeled,
 16 empty containers,
 16 incorrect laterality,
 14 incorrect tissue site,
 11 incorrect patient,
 9 no patient name,
 7 no tissue site,
 Procedures on the breast were the most common,
135
Labeling of Specimens
 2006 study found if 16,632 specimen errors
 1% were mislabeled,
 6.3% were requisition mismatches,
 4.6% were unlabeled specimens,
 Study found that strategies could be put in place to
reduce these and improve patient safety
 Working in interdisciplinary teams can improve safety
and outcomes (Nov 2006, Wagar, EA, Arch Pathol Lab
Med)
 2006 study found 1 out of every 18 causes adverse
event and about 160,000 AE per year in US from
misidentification of lab specimen (CAP 2006, Valenstein,
PN)
136
NQF Safe Practices 15 Discharge System
 A "Discharge Plan" must be prepared for each
patient at the time of hospital discharge, and a
concise discharge summary must be prepared for
and relayed to caregivers accepting responsibility
for postdischarge care in a timely manner
 Hospital must ensure that there is confirmation of
receipt of the discharge information by the LIP who
will assume the responsibility for care after
discharge
 TJC and CMS also require discharge summary
 TJC tracer on discharge process
137
15. Discharge Information
 One in 5 hospital discharges is complicated by
adverse event within 30 days
 Often leads to visits to the ED and rehospitalization
 National wide 25% of patients are readmitted within
90 days and 20% within 3 weeks of discharge
 CMS now monitoring 30 days readmission rates on some
diagnosis such as CHF and pneumonia (hospital compare)
 AHRQ has patient safety primer on adverse events after
hospital discharge on PSNet
 6% of discharges patient suffer severe harm and 33%
moderate harm potential
138
Preventing Unnecessary Readmissions
 Hospitals with higher than average readmission rates will be
financially penalized by CMS in 2012
 Hospitals should consider putting together a team to look at
preventing unnecessary readmissions
 NQF has published “Preferred Practices and Performance
Measures for Measuring and Reporting Care Coordination”
 November 2010 OIG report found that 44% of all adverse
events from unnecessary readmission were preventable
– OEI-06-09-00090 at ww.oig.hhs.gov
 The AHA published “Health Care Leader Action Guide to
Reduce Avoidable Readmissions”
139
AHA Guide to Reduce Readmissions
140
141
15. Patient Discharges
 Often because of errors from fragmentation of care
at discharge
 High rates of low health literacy, and lack of
coordination for post care lead to adverse events
 Need to do medication reconciliation (TJC
requirement)
 Need structured discharge communication
 AHRQ has Project Red to improve patient
discharges (Re-Engineered Hospital Discharges)
 http://www.ahrq.gov/news/kt/red/
142
15 Discharge System
 Need discharge P&P to include
 Roles in the discharge process
 Preparing for the discharge with documentation
throughout hospitalizations
 Complete discharge summary before discharge
 Reliable information flow from PCP to referring
caregiver and back
 Benchmarking, measurement, and continuous
quality improvement of discharge process
143
15 Discharge System
 Written discharge plan must be given to each patient
at the time of discharge
 That is understandable by the patient (remember
issue of low health literacy)
 Discharge plan needs to include reason for
hospitalization
 Medications to be taken post discharge
 What to do if condition changes
 Coordination and planning for follow up appointments
and follow up tests and for studies if results not
available at time of discharge
144
15 Discharge System
 Discharge summary needs to be provided to LIP
who is caring for the patient after discharge
 Current problem where 78% of LIP who see patient for
first visit do not have discharge summary
 Include reason for hospitalization and significant findings,
procedures done, medication list, list of tests and studies
of results and ones not back
 Copies of lab, x-ray reports, and tests results in hands of
person doing discharge summary
 Need receipt confirmation by physician caring for patient
after discharge of discharge summary by fax, phone,
email etc
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Discharge instructions
 Include activity level, medications and education on
medications, potential drug food interactions and follow up
information
 TJC RC.02.04.01 requires documentation of the patient’s
discharge information
 Document if you give patient specific patient education
sheets like fracture care sheet-should have copy on chart
 Ask Me 3 is three most important questions that can help
during discharge instructions
 What is the main problem?, what does the patient need to
do? And why it is important for them to do this?
(www.npsf.org/askme3)
146
16. CPOE Computer Provider Order Entry
 Implement a CPOE system built upon
the requisite foundation of reengineered evidence-based care,
 an assurance of healthcare
organization staff and independent
practitioner readiness,
 and an integrated information
technology infrastructure
 Increased use of CPOE expected in
light of meaningful criteria
147
CPOE
 Article on “Meaningful Use of Computerized
Prescriber Order Entry” was published in the March
2010 edition of Journal of Patient Safety
 Article provides a guide to those adopting CPOE
 Explains recent developments of important concepts and
developments such as meaningful use
 Discuss relevance of this and New ARRA/HITECH
regulations in regard to this Safe Practice
 Includes latest published studies in the area of CPOE
 The Safe Practice did not change but additional studies
are being published on impact on medication safety and
quality of care
148
www.safetyleaders.org/pdf/ClassenBatesDenham_Meanin
gfulUseCPOE_JPS2010Mar6(1)15-23-LTR.pdf
149
16. CPOE
 Studies show one of most important things you can
do to reduce medical errors
 Adoption of this may introduce new risks and
hazards
 Article by Koppel on 22 new types of errors from
CPOE
 Should facilitate medication reconciliation process
 Should link prescribing error-prevention software
with effective clinical decision support capability
 Prescribers must document any reason for override
an error prevention notice
150
16. CPOE
 Enable and facilitate timely display and review of all
new orders by pharmacist before the first dose of
medication unless it would cause harm
 CMS CoP Tag 500 and TJC MM chapter
requirement
 Computer system to display pertinent information
about the patient such as allergies, height, weight,
lab results, imaging, current medications and
problem list
151
Safe Practice 17 Medication Reconciliation
The healthcare organization
must develop, reconcile, and
communicate an accurate
patient medication list
throughout the continuum of
care.
Also a July 1, 2011 TJC
NPSG.03.06.01 and moved
from Goal 8
152
153
17 Medication Reconciliation MR
 Educate clinicians on importance of MR
 Providers who receive a patient in transition of care
should check list to make sure it is accurate
 List should include vitamins, OTC, samples,
prescribed, respiratory related, blood, IV solutions,
parental nutrition
 Get a complete list on admission
 Compare list of home meds to list in hospital and
keep list of home medications on separate form
 At time of transfer inform next provider
154
17 Medication Reconciliation
 At time of transfer to next service current list of
medication is communicated
 Give patient a current list of medications upon
discharge
 In setting where medications used minimally
(outpatient GI or ED) document list and consult list
if medications ordered along with allergies
 Complete documented list of medications and
reconcile
155
Culture
2007Culture
NQFSPReport
1
CHAPTER 1: Background
 Summary, and Set of
Safe Practices
Structures
& Systems
Team Training
& Team Interv.
Culture Meas.,
F.B., & Interv.
ID Mitigation
Risk & Hazards
CHAPTER 2: Creating and Sustaining a Culture of
Patient Safety
• Leadership Structures & Systems
• Culture Measurement, Feedback and Interventions
• Teamwork Training and Team Interventions
• Identification and Mitigation of Risks and Hazards
Consent&&Disclosure
Disclosure
Consent
Informed
Consent
Life-Sustaining
Treatment
CHAPTER 3: Informed Consent & Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
Disclosure
Workforce
CHAPTERS 2-8 :
Practices By Subject
Nursing
Workforce
Direct
Caregivers
CHAPTER 4: Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care
ICU Care
Information Management & Continuity of Care
CHAPTER 5: Information Management & Continuity of
Care
• Critical Care Information
• Order Read-back
• Labeling Studies
• Discharge Systems
• Safe Adoption of Integrated Clinical Systems
including CPOE
• Abbreviations
CHAPTER 6: Medication Management
• Pharmacist Role (Safe Practice 18)
• Medication Reconciliation
Management
•Medication
High-Alert
Medications
.
• Standardized Medication
Labeling & Packaging
• Unit-Dose Medications
Critical
Care Info.
Labeling
Studies
Order
Read-back
Discharge
System
CPOE
Abbreviations
•
Med Recon
Pharmacist
Central Role
High Alert
Meds
Std. Med
Labeling & Pkg
Unit Dose
Medications
Hospital Acquired Infections
•
Asp. + VAP
Prevention
Hand Hygiene
Influenza
Prevention
Central V. Cath
BSI Prevention
Sx Site Inf.
Prevention
Condition- & Site-Specific Practices
EvidenceBased Ref.
Press. Ulcer
Prevention
Anticoag.
Therapy
Wrong-site
Sx Prevention
Periop. MI
Prevention
DVT/VTE
Prevention
Contrast
Media Use
CHAPTER 6: Medication Management
• Medication Reconciliation
• Pharmacist Role
Standardized Medication Labeling & Packaging
• High-Alert Medications
• Unit-Dose Medications
CHAPTER 7: Hospital-Acquired Infections
• Prevention of Aspiration and VentilatorAssociated Pneumonia
Central Venous Catheter-Related Blood Stream
Infection Prevention
• Surgical Site Infection Prevention
• Hand Hygiene
• Influenza Prevention
CHAPTER 8:
• Evidence-Based Referrals
• Wrong-Site, Wrong Procedure, Wrong Person
Surgery Prevention
• Perioperative Myocardial Infarct/Ischemia
Prevention
• Pressure Ulcer Prevention
• DVT/VTE Prevention
• Anticoagulation Therapy
156
• Contrast Media-Induced Renal Failure Prevention
18 Pharmacy Leadership Structure & Systems
Pharmacy leaders should
have an active role on
the administrative
leadership team that
reflects their authority
and accountability for
medication management
systems performance
across the organization.
157
18 Pharmacy Leadership
 Need a structure in place to ensure that pharmacy
leaders engage in regular and direct
communication with board and senior leaders about
MM systems
 Pharmacists
 Work with interdisciplinary team to ensure safe
medication use across continuum
 Make sure organization knows of medication safety gaps
 Adequate budget for PI and to ensure action for safety
medication use
158
18 Pharmacy Leadership
 Support a culture of safe medication use
 Identify and mitigate safety risks and hazards
 Work with teams to ensure evidenced based
medication practices
 Has section on storage of medication, ordering and
transcribing and preparing and dispensing
 Written medication storage policy (top TJC problematic
standard)
 TJC has a sections in MM.01.02.01 chapter and moved
from the 2010 NPSG.02.02.02
 Identify and review annually LASA drugs
159
TJC LASA Drugs MM.01.02.01
The hospital addresses the safe use of lookalike/sound-alike (LASA) medications
 It is a much bigger problem according to recent
research so USP has database hospitals can
check for LASA drugs
 8th Annual MedMaRX report issued in 2008
shows problems with 3,170 drug pair names
which is doubled number since 2004
 Oxycontin confused with oxycodone
 Cerebyx confused with celebrex
160
TJC LASA Drugs MM.01.02.01
 TJC no longer maintains a LASA list so refer to the
ISMP list
 EP1 The hospital develops a list of LASA
medications it stores, dispenses, or administers
 ISMP publishes a list of LASA drugs
 USP publishes list of LASA drugs at
http://www.usp.org/pdf/EN/patientSafety/qr792004-0401.pdf
 MedMarx article at
www.usp.org/pdf/EN/patientSafety/capsLink2008-0401.pdf
161
LASA Drugs 01.02.01
EP2 The hospital takes action to prevent
errors involving the interchange of the
medications on its list of LASA medications
EP3 The hospital annually reviews and, as
necessary, revises its list LASA medications
 So in your policy need to includes
precautions for LASA medications
162
TJC No Longer Has List of LASA Drugs
163
164
165
LASA Drugs 01.02.01
 Heparin mix up
 Bottles looked alike
and were stored
next to each other
 Red warning labels
should be placed
on neuromuscular
blockers
166
18 Pharmacy Leadership
 Pharmacist review all medications orders before
dispensed
 Documents actions taken if any problems
 Pharmacist oversee preparation of medications
including sterile products (USP 797 regulations)
 Medications should be labeled appropriately
 TJC MM standard and NPSG
 Medication errors and near misses are reported
external (PSO, FDA, ISMP, USP)
167
18 Pharmacy Leadership
 Identify high alert medications in organization and
have process for storing, ordering, dispensing and
monitoring
 CMS Tag 490 has a requirement for P&P on high alert
medications
 TJC has high alert requirements in MM.01.01.03
 ISMP has a list of high alert medications
 IHI has how to guide to prevent harm from high alert
medications
 WPSI has a sample policy on high alert medications
 Hospitals should have a safe injection practices policy
and should contain CDC guidelines
168
MM.01.01.03 High Alert Medication
 Standard: Hospital needs to safety manage both
high alert and hazardous medications
 Rationale: High alert medications are those that
account for a large number of medication errors
and sentinel events
 ISMP has a list of high alert medications
 IHI has how to guide to prevent harm from high
alert medications
 WPSI has a sample policy on high alert
medications
169
http://ismp.org/Tools/highalertmedications.pdf
170
www.ihi.org/NR/rdonlyres/8B2475CD-56C7-4D9B-B359801F3CC3A8D5/0/HighAlertMedicationsHowToGuide.doc
171
TJC High Risk Meds MM.01.01.03
EP1 Define your list high alert medicines and
hazardous medications in writing
 EC.02.02.01 EP 8 Hospital minimizes risks
associated with disposing of hazardous
medications
EP2 Define a special process for managing high
alert and hazardous drugs
 EC.02.02.01 EP 8 above
 MM.03.01.01 EP 9 Concentrated electrolytes are
only in patient care units where necessary and
precautions are taken
172
TJC High Risk Meds
EP3 Implement your process for high alert
and hazardous medications
 EC.02.02.01 EP1 Hospital maintains current
inventory of hazardous material and waste that
is uses, stores, or generated
 Inventory only materials required by law
 EC.02.02.01 EP8 Hospital minimizes risk with
disposing of hazardous materials
173
TJC High Risk Meds
 EP5 Hospital must report abuses and losses of
controlled substances to pharmacy department
and CEO
 This for hospitals that use TJC for deemed
status so it is most hospitals except VA and
Shriners
 This is a CMS CoP requirement for hospitals
 CMS also requires a high risk policy in the
hospital CoPs (490)
174
175
176
Pharmacist Involvement
 Pharmacist perform self assessment to identify
opportunities for improvement
 TJC requires annual review of medication management
system
 Evaluate patient ability to understand and adhere
to medication regimens
 Remember issue of low health literacy
 20% of patients read at 5th grade level
 AHRQ has tool s and a pharmacy health literacy center
177
http://pharmacyhealthliteracy.ahrq.gov/sites/PharmHealthLiteracy/defa
ult.aspx
178
179
The End
Questions??
 Sue Dill Calloway RN, Esq.
CPHRM
 AD, BA, BSN, MSN, JD
 President
 5447 Fawnbrook Lane
 Dublin, Ohio 43017
 [email protected]
 614 791-1468
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