Transcript National Safety Goals

NATIONAL PATIENT
SAFETY GOALS
FY 2008
Recommended by the Sentinel
Event Alert Advisory Group
NATIONAL PATIENT SAFETY
GOALS FY 2008
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Improve Accuracy of Patient Identification
Improve Effective Communication Among
Caregivers
Improve Safety of Using Medications
Reduce Risk of Health Care-Associated
Infections
Accurately and Completely Reconcile
Medications Across Continuum of Care
NATIONAL PATIENT SAFETY
GOALS FY 2008
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Reduce the Risk of Patient Harm
Resulting from Falls
Encourage Patient’s Active
Involvement in Their Own Care as a
Patient Safety Strategy
The Organization Identifies Safety
Risks Inherent in its Patient
Population
NATIONAL PATIENT SAFETY
GOALS FY 2008
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Reduce the Risk of Influenza and
Pneumococcal Disease in
Institutionalized Older Adults
Prevent Health Care-Associated
Pressure Ulcers
NATIONAL PATIENT SAFETY
GOALS FY 2008
Health Care Organizations are
required to demonstrate how the
organization is meeting the patient
Safety Goals.
This CBL will explain the compliance
requirements for each of the Safety
Goals.
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GOAL 1:
Improve the Accuracy of Patient
Identification
A) Use at least two patient identifiers (not
the patient’s room number) when:
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Administering medications or blood products
Taking blood (or other) samples for clinical testing
Providing care, treatment, procedure, or services
GOAL 1:
Improve the Accuracy of Patient
Identification
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Identifiers that may be used:
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The patient’s name
Patient’s birth date
Assigned identification number
Patient’s Social Security number
Patient’s telephone number or address
Bar coding (includes two or more indicators)
Photo ID
GOAL 1:
Improve the Accuracy of Patient
Identification
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Identifiers used for unconscious
patient:
 Family may verify the patient ID
 EMS/ Police verify the patient ID
 Assign John/Jane Doe
GOAL 1:
Improve the Accuracy of Patient
Identification
B) JCAHO requires three items be
verified prior to the start of any invasive
or surgical procedure:
Conduct a final verification process such
as “time out” to confirm:
correct patient
 correct procedure
 correct site
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GOAL 1:
Improve the Accuracy of Patient
Identification
Must use ‘active’ communication
techniques by all team members
Definition of ‘active’ communication:
 Affirmation - orally or by some action
 Involves everyone’s participation
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
A) Implement a process for taking verbal
or telephone orders that requires a
verification “read back” of the complete
order by the person receiving the
order.
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
Write purpose of the medication
 Implement policy for verbal or
telephone orders
 Provide generic and brand names
on all medication labels
 Provide patient written information
about their drugs
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GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
Record verbal/phone order
directly onto order sheet in
patient’s chart
 Read back order to the
prescriber
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GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
Verbal orders must contain:
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Patient’s name
Medication specifics:
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2.
3.
4.
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6.
7.
Name of drug
Dose
Route
Frequency
Duration (if applicable)
Purpose of medication (if given as prn)
Any additional instructions
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
Standardize the abbreviations
used throughout the organization,
including a list of abbreviations,
acronyms and symbols not to use
B)
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
DO NOT USE…
U---------------IU - - - - - - - - - - - - - - MS - - - - - - - - - - - - - - MgSO4 - - - - - - - - - - - MSO4 - - - - - - - - - - - - QD - - - - - - - - - - - - - - QOD or qod - - - - - - - - X.0 mg (trailing zero)- - - .X mg (leading zero)- - - - -
Correct Way to Write…
Unit
International Unit
Morphine Sulfate
Magnesium Sulfate
Morphine Sulfate
Every Day
Every Other Day
X mg
0.X mg
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
Notify the nurse if you see unapproved
abbreviations in useThe “Do Not Use Abbreviations” list is
printed at the top of the MD Order
Sheets.
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
C) Measure, assess, and if appropriate,
take action to improve the timeliness of
reporting, and the timeliness of receipt
by the responsible licensed caregiver, of
critical test results and values
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
D) All values defined as “critical” by the
laboratory are reported directly to a
responsible licensed caregiver within
timeframes established by the
organization. When the patient’s
responsible licensed caregiver is not
available within the timeframes, there is a
mechanism to report the critical
information to an alternate caregiver.
GOAL 2:
Improve Effectiveness of
Communication Among Caregivers
E) Implement a
standardized approach
to “hand off”
communications,
including an opportunity
to ask and respond to
questions.
GOAL 3:
Improve the Safety of
Using Medications
A)
 Standardize and limit
drug concentrations
available in the
organization
GOAL 3:
Improve the Safety of
Using Medications
B) Identify and, at a minimum,
annually review a list of look-alike,
sound-alike drugs used in the
organization, and to take action to
prevent errors involving the
interchange of these drugs
GOAL 3:
Improve the Safety of
Using Medications
C) Label all medications,
medication containers (e.g.,
syringes, medicine cups,
basins), or other solutions on
and off the sterile field in
perioperative and other
procedural settings.
GOAL 4:
Reduce the Risk of
HealthCare-Associated Infections
Comply with current CDC hand-hygiene
guidelines (contained within Infection
Control CBL)
 Manage as sentinel events all identified
cases of unanticipated death or
permanent loss of function associated
with a health care-associated infection.
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GOAL 5:
Accurately and Completely Reconcile
Medications Across the Continuum of Care
A) Implement a process for obtaining
and documenting a complete list of the
patient’s current medications upon the
patient’s admission to the organization
and with the involvement of the patient.
This process includes a comparison of
the medications the organization
provides to those on the list.
GOAL 5:
Accurately and Completely Reconcile
Medications Across the Continuum of Care
B) A complete list of the patient’s
medication is communicated to the next
provider of service when it refers or
transfers a patient to another setting,
service, practitioner or level of care
within or outside the organization.
GOAL 5:
Accurately and Completely Reconcile
Medications Across the Continuum of Care
C)
The complete list of medications is also
provided to the patient on discharge
from the facility.
GOAL 5:
Accurately and Completely Reconcile
Medications Across the Continuum of Care
Completion of a Computer-Based
Learning Program devoted to the
Medication Reconciliation process will
be required of staff who are
responsible for administration of
medications.
GOAL 6:
Reduce the Risk of Patient Harm
Resulting from Falls
A) Assess and periodically
reassess each patient’s risk for
falling, including the potential
risk associated with the
patient’s medication regimen,
and take action to address any
identified risks
GOAL 6:
Reduce the Risk of Patient Harm
Resulting from Falls
B) Implement a fall
reduction program,
including a transfer
protocol, and evaluate
the effectiveness of
this program
GOAL 7:
Encourage Patient’s Active
Involvement in Their Own Care as a
Patient Safety Strategy
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Define and communicate the
means for patients and their
families to report concerns
about safety, and encourage
them to do so.
GOAL 7:
Encourage Patient’s Active
Involvement in Their Own Care as a
Patient Safety Strategy
GOAL 8:
The Organization Identifies Safety
Risks Inherent in its Patient Population
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The organization identifies
patients at risk for suicide.
[Applicable to psychiatric
hospitals and patients being
treated for emotional or
behavioral disorders in
general hospitals.]
GOAL 9:
Reduce the Risk of Influenza &
Pneumococcal
Disease in Institutionalized Older Adults
Goal #9 pertains specifically to the
following populations:
a.) Assisted Living
b.) Disease-Specific Care
c.) Long Term Care
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GOAL 9:
Reduce the Risk of Influenza &
Pneumococcal
Disease in Institutionalized Older Adults
A) Develop and implement a protocol
for administration and documentation of
the flu vaccine
B) Develop and implement a protocol
for administration and documentation of
the pneumococcus vaccine
GOAL 9:
Reduce the Risk of Influenza &
Pneumococcal
Disease in Institutionalized Older Adults
C) Develop and implement a protocol to
identify new cases of influenza and to
manage an outbreak
GOAL 10 :
Prevent Health Care-Associated
Pressure Ulcers
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Most pressure ulcers can be
prevented.
Deterioration at Stage 1 can be halted.
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Teach staff to reduce incidence.
Assess patients using Braden Scale to
identify patients at risk and provide
nutritional support when needed.
Increase activity and mobility of patients.
Reposition patients while avoiding shear
and friction injury.
GOAL 11:
Reduce the Risk of Surgical Fires
Goal #11 pertains to the following settings:
a.) Ambulatory Surgery
b.) Office-Based Surgery
GOAL 11:
Reduce the Risk of Surgical Fires
A) Educate staff, including operating
licensed independent practitioners and
anesthesia providers, on how to
control heat sources and manage
fuels, and establish guidelines to
minimize oxygen concentration under
drapes
NATIONAL PATIENT SAFETY
GOALS FY 2008
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