National National Patient Safety Patient Safety

GoalsGoals

20112011

Medical errors are one of the nation’s leading cause of Medical errors are one of the nation’s leading cause of death and injury.death and injury.

The Institute of Medicine estimates as many as 44,000 to The Institute of Medicine estimates as many as 44,000 to 98,000 people die each year as a result of medical errors.98,000 people die each year as a result of medical errors.

Beginning in 2003, The Joint Commission has enforced Beginning in 2003, The Joint Commission has enforced national patient safety goals for healthcare organizations national patient safety goals for healthcare organizations to strive for in order to increase patient safety. to strive for in order to increase patient safety.

The Joint Commission has identified five Patient Safety Goals & 1 Universal Protocol to improve patient safety:

1. Improve the Accuracy of Patient Identification2. Improve the Effectiveness of Communication

among Caregivers3. Improve the Safety of Using Medications4. Reduce the Risk of Healthcare-Associated

Infections5. The Organization Identifies Safety Risks

Inherent in its Patient Population U.P. Prevent wrong-site, wrong-procedure and

wrong patient procedures

1.1. Improve the Accuracy of Patient Improve the Accuracy of Patient IdentificationIdentificationStandard: Standard: Use at least two (2) patient identifiers.Use at least two (2) patient identifiers.

Patient Identifiers must be used….Patient Identifiers must be used…. When administering medicationsWhen administering medications

When administering blood productsWhen administering blood products

When taking blood samples & other specimensWhen taking blood samples & other specimens

When providing any other treatments or proceduresWhen providing any other treatments or procedures

At SLRHC……..At SLRHC…….. To confirm a

patient’s identity Ask the patient’s

name Ask for the patient’s

date of birth

Can you tell me your name and date of birth?

For a patient who cannot respond:

Check patient’s ID band

Compare ID band to PRISM record or requisition slip

In an emergency situation - patient may receive treatment prior to identification if the treatment is deemed necessary to stabilize the patient’s condition.

1.1. Improve the Accuracy of Patient Improve the Accuracy of Patient Identification Identification (cont’d) (cont’d)Standard:Standard: Eliminate transfusion errors related to patient Eliminate transfusion errors related to patient

misidentification.misidentification. Before initiating a transfusion, the patient is matched to Before initiating a transfusion, the patient is matched to

the blood / blood component the blood / blood component during a two-person during a two-person verification process.verification process.

2. Improve the Effectiveness of Communication among Caregivers

Standard:Standard: Report critical results of tests and diagnostic procedures Report critical results of tests and diagnostic procedures

on a timely basis.on a timely basis. Lab or diagnostic department personnel will notify appropriate

staff (MD/PA/NP or RN) as soon as possible, but no longer than 30 minutes after the result is available.

STAT requests are treated as alert requests and will be reported within 1 hour of receipt.

The nurse is responsible to notify the provider within 1 hour of the time the result is received.

3. Improve the Safety of Using Medications

Standards: Label all medications, medication containers (i.e.

syringes, medicine cups, basins) or other solutions on or off the sterile field.

Reduce the likelihood of harm associated with the use of anticoagulation therapy.

3. Improve the Safety of Using Medications (cont’d)

Standards:Standards: Maintain and communicate accurate patient Maintain and communicate accurate patient

medication information.medication information. Reconcile all medications the patient is currently taking

and document this information in the medical record.

Provide written information on the medications the patient should be taking upon discharge from the hospital.

4. Reduce the Risk of Healthcare-Associated Infections

Standards: Comply with CDC hand hygiene guidelines.

Our Hand Hygiene Team monitors staff compliance with hand hygiene.

At SLRHC……..

Signs are posted as a reminder to wash hands before and after patient contact.

Alcohol-based hand cleansers are placed in designated patient care areas.

4. Reduce the Risk of Healthcare-Associated Infections (cont’d)Standards: Implement evidence-based practices to prevent health

care-associated infections due to multidrug-resistant organisms.

Implement evidence-based practices to prevent central line-associated bloodstream infections.

Implement evidence-based practices for preventing surgical site infections.

5. The organization identifies safety risks 5. The organization identifies safety risks inherent in its patient populationinherent in its patient population

Standard: Standard: Identify patients at risk for suicide.Identify patients at risk for suicide.

At SLRHC….At SLRHC…. All patients admitted for emotional or behavioral All patients admitted for emotional or behavioral

disorders are assessed throughout their stay for disorders are assessed throughout their stay for

suicide risk.suicide risk. Patients on the general inpatient unit are Patients on the general inpatient unit are

assessed on admission for suicidal history or assessed on admission for suicidal history or

ideation.ideation.

Universal Protocol: Prevent Wrong-Site, Universal Protocol: Prevent Wrong-Site, Wrong-Procedure and Wrong Patient Wrong-Procedure and Wrong Patient

ProceduresProcedures Conduct a Conduct a pre-procedure verificationpre-procedure verification process. process. MarkMark the procedure site. the procedure site. Implement a Implement a TIME OUTTIME OUT immediately before immediately before

starting the procedure to confirm:starting the procedure to confirm: Correct patientCorrect patient Correct procedureCorrect procedure Correct site/locationCorrect site/location Correct sideCorrect side Correct positionCorrect position Correct implant (when applicable)Correct implant (when applicable) Correct supplies/equipment availableCorrect supplies/equipment available

At SLRHC……At SLRHC…… Verification is conducted by all of the team Verification is conducted by all of the team

membersmembers

Site is marked with the proceduralist’s initials Site is marked with the proceduralist’s initials for all procedures involving lateralityfor all procedures involving laterality

““TIME OUT”TIME OUT” is used prior to the start of the is used prior to the start of the procedure and involves procedure and involves ALLALL team members team members