Slide 2 National Patient Safe

National Patient Safety Goals Presented by: LTC Margaret Dixon

Purpose • Familiarize staff with the National Patient Safety Goals • Explain their intend • Discuss how to comply in nursing practice

JCAHO • 2003 NPSGs recommendations surveyed beginning Jan.1, 2003 • Failure to implement = Type I recommendation • Almost 50% of JCAHO standards are directly related to safety

• Doctors, nurses, & other health professionals are not being adequately prepared to provide the highest quality and safest medical care possible. • All programs that educate & train health professionals should adopt 5 core competencies: abilities to deliver patient-centered care, work as a member of an interdisciplinary team, engage in evidence-based practice, apply QI approaches and use information technology • Patients, and often their families, play a key role in their care and safety.

2004 National Patient Safety Goals

• Improve the accuracy of patient Identification. 2. Improve the effectiveness of communication among caregivers. 3. Improve the safety of using high-alert medications. 4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery. Universal Protocol 5. Improve the safety of using infusion pumps.

2005 National Patient Safety 1. Accurately and completely reconcile medications across the continuum of care 2. Reduce the risk of patient harm resulting from falls 10. Reduce the risk of surgical fires

2006 National Patient Safety Goals 1. Patient Identification 2. Medication Safety 3. Communication among caregivers 4. Universal Protocol 5. Retired 6. Retired 7. Health care-associated infections 8. Reconciliation of medications 9. Patient falls 10. Flu & Pneumonia immunization 11. Surgical fires 12. NPSG implementation by network components 13. Patient involvement 14. Pressure ulcers

1. Improve the accuracy of patient identification • 1.a. Use at least two patient identifiers whenever taking blood samples or administering medication or blood products. • 1.b. Universal Protocol – “Time Out”

1. Improve the accuracy of patient identification • Possible identifiers – The patient’s name – Social Security number with prefix (20, 30, 01 …) – Assigned identification number – Patient’s birth date – Telephone number – Address

1. Improve the accuracy of patient identification • Does not require that 2 identifiers be physically separate • With unresponsive patients can have family member verify the patient’s identity • Verifying identification with the ID band and having the patient state their name

1. Improve the accuracy of patient identification Do’s & Don’ts for Pt-Blood • Do Product match the pt’sID name & ID number to blood product documentation • Do have at least 2 individuals check • Don’t use the patient’s room number or bed number • Don’t ask a colleague to verify without matching to blood

2. Improve the effectiveness of communication among • caregivers a. Implement a process for taking verbal or telephone orders that requires verification “read-back” of the complete order by

the person receiving the order; read back critical test results . • b. Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols NOT to use. • 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 and lab values • e. Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions

2a. Tips for Improving the Use of Telephone Orders

• Instill a habit of enunciating clearly and repeating. • Pronounce digits separately • Spell out drug names • Avoid abbreviations • *****Read back the order***** • Have second person listen to verbal order • Record the verbal order directly onto an order sheet in the patient’s chart if possible

2.b Standardization of abbreviations, acronyms, and symbols

• 5 Types of Problem-Prone Abbreviations

– Bad handwriting or typo; Signs; Greek letters; Latin terms and abbreviations; Ambiguity (more than one meaning)

• Use of “trailing zero” will continue to be prohibited for medication dosages • Recommendations from “Summit”

DO NOT USE Abbreviations Item 1 2

3

4

5 6 7 8 9

DANGEROUS ABBREVIATIONS POTENTIAL PROBLEMS U (for unit) Mistaken for zero, four or cc Mistaken as IV (intravenouls) or 10 IU (for International unit) (ten)

PREFERRED TERM Write "unit" Write "International unit"

Q.D.

Mistaken for QOD. The period after the Q can be mistaken for an "I" and the "o" can be mistaken for an "I" Write "daily"

Q.O.D.

Mistaken for Q.D. The period after the Q can be mistaken for an "I" and the "o" can be mistaken for an "I" Write "every other day"

Trailing Zero (X.0) Lack of trailing Zero (.X) MS MS04 MgS04

10

ug (for microgram)

11

c.c. (for cubic centimeter)

Decimal point is missed Confused for one another. Can mean morphine sulfate or magnesium sulfate Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose Mistaken for U (units) when poorly written

Never write a zero by itself after a decimal point (Xmg), and always use a zero before a decimal point (0.Xmg) Write "morphine sulfate" or "magnesium sulfate" Write "mcg" or "microgram" Write "ml" for milliliters

Summit Recommendations • Focus on first nine abbreviations • Scope of applicability of the “do not use” list - All orders (not just medication orders) - All medication-related documentation (orders, transcriptions, MAR, progress notes) - Includes all handwritten documentation; preprinted forms, but not to computer generated forms or displays • Expected level of compliance – 100% of preprinted forms and up to maximum of 95% after 2005 with handwritten documentation

2e. Implement a standardized approach to “hand off”

• Needs to include an opportunity to ask and respond to questions • Required anytime there is a change in responsibility (e.g. change of shift) • MEDCEN policy 40-46 • Hand off form FH MDA OP 491 (Feb 06)

3. Improve the safety of using medications • 3b. Standardize and limit the number of drug concentrations available in the organization • 3c. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take actions to prevent errors. • 3d. Label all medications, medication containers (e. g. syringes, med cups, basins) or other solutions on and off the sterile field in perioperative and other procedural settings

High-alert Medications 1. Insulin 2. Opiates and narcotics 3. Injectable potassium chloride/phosphate concentrate 4. Intravenous anti-coagulants (heparin) 5. Allergy extracts 6. Benzadrine Sprayed Agents 7. Clotting factors 8. Epinephrine 1:1000 9. Thrombolytics 10. Vaccines 11. Propofol 12. Chemotherapeutics 13. Pediatric/Neonatal TPN 14. Etomidate

4: UNIVERSAL PROTOCOL • Preoperative verification process - relevant pre-op tasks completed and information is available and correct

• Surgical site marking - unambiguous mark, visible after prep & drape - right/left, mutliple structures or levels

• “Time Out” immediately before starting - involves entire team; active communication - fail-safe model; “No Go” unless all agree

• Applies to invasive procedures in all settings

UNIVERSAL PROTOCOL • Does not apply to: Minor routine procedures such as • Venipuncture • Peripheral IV line placement • Insertion of NG tube • Foley catheter insertion

• Does apply to: Most other procedures that involve puncture or incision of the skin, or insertion of an instrument or foreign material into the body, including, but not limited to: -percutaneous aspirations -biopsies -cardiac & vascular catheterizations -endoscopies

Marking the operative site • Procedures not required to be marked: – – – – –

mid-line sternotomy C-section Laparotomy Laparoscopy Interventional procedures for which the site is not predetermined – Procedures done through or immediately adjacent to “natural body orifices

UNIVERSAL PROTOCOL • Pre-operative verification process – FH MDA OP 391: preoperative verification process/checklist, to confirm that appropriate documents ( e.g., medical records, imaging studies) are available. – Missing information or discrepancies must be addressed prior to starting the procedure – Ongoing process of information gathering and verification through all stages

Marking the operative site • For procedures involving right/left distinction, multiple structures, or multiple levels • Surgical mark must be still visible after surgical drapes are in place • At CRDAMC, surgeon initials the site • Ask patients before marking if they have any sensitivity/allergy to inks • Involve patient in process

Marking the operative site • Non-operative site MUST NOT be marked • Adhesive markers(“stickies”) should NOT be used as the sole means of marking site

5. Improve the safety of using infusion pumps. • Retired, incorporated into EC.6.20, EP #2 • Ensure free-flow protection on all general-use and PCA intravenous infusion pumps used in the organization – CRDAMC has standardized to Alaris pumps

6. Improve the effectiveness of clinical alarm systems •Retired and incorporated into EC.6.20 •6a. Implement regular preventive maintenance and testing of alarm systems. •6b. Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

Included alarm systems • • • • • • •

Cardiac monitor alarms Apnea monitors Door alarms in behavioral health settings Cell-salvaging devices Elopement/abduction alarms Infusion pumps Alarms associated with gas pressure or concentration • Fraction of inspired O2 (FIO2) from ventilator • Exhaled CO2 fraction in the OR • Emergency assistance – “panic buttons”

7. Reduce the risk of health careacquired infections • Refer to Ms Munn’s Infection Control briefing • Comply with current CDC hand-hygiene guidelines. • Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.

8. Accurately and completely reconcile medications across the continuum of care • Develop a process for obtaining and documenting a complete list of patient’s current medications upon admission, involve the patient in the process. Compare to medications the hospital can supply • A complete list of patient’s medications are communicated to the next provider when referring or transferring the patient • MOM form FH MDA OP2-e

9. Reduce the risk of patient harm resulting from falls • Implement a fall reduction program, including a transfer protocol, and evaluate the effectiveness of the program • Policy being updated, training to follow • Notify safety if see a safety hazard (sidewalks, slippery floors)

10. Reduce influenza and pneumococcal disease

• Process in place for those over 65 to receive pneumovax. MEDCOM Policy 06-023 • Inpatient: form…mainly used on 3South • Outpatient – annotated in AHLTA

11. Reduce the risk of surgical fires • Educate staff, including LIPs and anesthesia providers, on how to control heat sources and manage fuels • Establish guidelines to minimize oxygen concentration under drapes.

14. Pressure Ulcers • Policy being developed by multidisciplinary team - see MAJ Robison, Med-Surg CNS if interested in participating on this team

• Wound specialist presented CE in June regarding care of wounds and pressure ulcers

QUESTIONS?