Transcript Patient_Safety_Goals.. - University of Illinois at Chicago

2009 National Patient
Safety Goals
Kathleen Killoran, MS, RN-BC
Created 8/18/2009
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 # 1
Improve 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 # 1
Improve 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
PATIENTS
Patient Safety Question?
What are the 3
patient
identifiers used
at IMMC?
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IDENTIFICATION OF
PATIENTS
Patient Safety Answer:
The Pt Name,
DOB
&
Medical Record #
on the armband
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ARMBANDS
Patient Safety Question?
Name 3
occasions
when you
should check
the patient’s
armband?
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ARMBANDS
Patient 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
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the unit.
GOAL #2
Improve 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
Ug
mcg
cc
ml
5.0 mg
5mg
MS
DO NOT USE
U
unit
IU
QD
daily
QOD
International Unit
Every other day
.25 mg
0.25mg
MSO4
SC or SQ
SubQ
MgSO4
Morphine Sulfate or Magnesium
Sulfate
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GOAL #2 Improve the effectiveness of
Communication among Caregivers cont.
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
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– Precautions
GOAL #2 Improve the effectiveness of
Communication among Caregivers cont.
Patient Safety Question?
What is the process of
communicating relevant
patient information to
another clinician?
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GOAL #2 Improve the effectiveness of
Communication among Caregivers cont.
Patient Safety Answer:
“Handoff”
The RN is responsible for completing
the
Hall Pass or Patient Transport Tool
when the patient leaves the floor
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GOAL #3 Improve the Safe Use of
Medications
• 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
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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 Coumadin
 Monitor PTT when patients are receiving IV Heparin
 Educate patient/family on anticoagulation therapy
 Individualize 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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Goal # 7: Reduce the Risk of
Health Care Acquired Infections
cont.
• 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 catheterassociated urinary tract infections.
• All associates must be educated annually on
MDROs, and HAI infection prevention strategies.
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Goal # 7: Reduce the Risk of
Health Care Acquired Infections
cont.
Patient Safety Question?
What is the #1
safeguard to
prevent
Health Care
Acquired
Infections?
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Goal # 7: Reduce the Risk of
Health Care Acquired Infections
cont.
Patient Safety Answer:
Hand Hygiene!
Hand Hygiene!
Hand Hygiene!
See Hand Hygiene Policy (90.017.038)
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Goal # 7: Reduce the Risk of
Health Care Acquired Infections
cont.
• 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.
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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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Goal 8: Accurately and completely
reconcile medications across the
continuum of care
cont.
Patient Safety Question?
• 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.
What process would have
caught this error before it
reached the patient?
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Goal 8: Accurately and completely
reconcile medications across the
continuum of care
cont.
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.
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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.
Patient Safety Question?
When does
Medication
Reconciliation
need to be
done for my
patients?
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Goal 8: Accurately and completely
reconcile medications across the
continuum of care
cont.
Patient Safety Answer:
Upon:
1. Admission
2. Transfer(s)
(different level of care)
3. Discharge
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Goal 9: Reduce the risk of patient
harm resulting from falls
Patient Safety Question?
What is the
number one
nursing liability
related to
patient safety?
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Goal 9: Reduce the risk of patient
harm resulting from falls cont.
Patient Safety Answer:
Patient falls
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Goal 9: Reduce the risk of patient
harm resulting from falls cont.
Patient Safety
Question?
What are examples of
fall risk reduction
interventions?
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Goal 9: Reduce the risk of patient
harm resulting from falls cont.
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
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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
Emergency Department will be
screened by the nurse for suicide risk
•The admitting RN will ask the suicide
screening question on patients
•Implement Suicide Precautions
immediately if the patient is at risk of
harming 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 # 1
Elimination Wrong Site,
Procedure, Person, Surgery
– Timeouts
– EVERYONE participates!!!
– Site Marking
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2009 JCAHO
National Patient Safety Goals
cont.
Patient Safety Question?
What is
Advocate’s
RED RULE?
?
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2009 JCAHO
National Patient Safety Goals
cont.
Patient Safety Answer:
Time OUT
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2009 JCAHO
National Patient Safety Goals
cont.
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
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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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2009 JCAHO
National Patient Safety Goals
cont.
Don’t forget! The “TIME-OUT
process applies to procedures
OUTSIDE the OR as well!
Rule of thumb: Anything that may
require a consent and/or is a “high risk”
procedure requires a TIME-OUT
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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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REFERENCES:
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.
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