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MARTINARMYCOMMUNITYHOSPITAL
COMPLIANCEWITHTHE
NATIONALPATIENTSAFETYGOALS
NPSG1: IMPROVEPATIENTIDENTIFICATION
When
providing
care,
treatment
and
services
to
apatient
we
are
to
verify
we
have
the
right
patient.
WeuseNAMEandDATEOFBIRTH.
Anytimeaspecimeniscollectedwemustlabelthecontainerinthepresenceofthepatient.
NPSG2:IMPROVECOMMUNICATION
Anytimeaverbalortelephonicorderisgivenortelephonereportingofcriticaltestresults,theperson
receivingtheordermustREADBACKthecompleteorderortestresult.
StandardizealistofabbreviationsNOTtousethroughoutthefacility.
UWriteunit
IUWriteinternationalunit
Q.D.
Write
every
day
Q.O.D.Writeeveryotherday
TrailingzeroWrite5mgdonotuse5.0mg
LackofleadingzeroWrite0.5mgdonotuse.5mg
MSWritecompletenameofmedication
MSO4Writecompletenameofmedication
MgSO4Writecompletenameofmedication
Implementastandardizedapproachtohandoffcommunication.
OurprocessiscalledBSTAR
(background,situation,treatment,assessment,recommendation).
NPSG3:IMPROVESAFETYOFUSINGMEDICATIONS
Identify
alist
of
look
alike/sound
alike
medications
and
take
action
to
prevent
errors
involving
these
medications.
EphedrineandEpinephrine ClonidineandClonazepam
Insulin(Novologvs.Novolin) CelebrexandCelexaandCerebyx
OxycontinandOxycodone ZyprexaandZyrtecandZantac
DilaudidandDuramorph ToprolXLandTopamax
LamisilandLamictaland PrilosecandProzac
Levetiracetam(Keppra) WellbutrinSRandWellbutrinXL
MetforminandMetronidazole Abilify(Arripiprazole)and
AvandiaandCoumadinandCardura OmeprazoleandEsomeprazole
Label
all
medications,
medication
containers
or
other
solutions
on
and
off
the
sterile
field.
When
you
takeamedicationorsolutionoutofitsoriginalcontainerandplaceitinanother,thecontainerwillbelabeled.
Reducethelikelihoodofpatientharmassociatedwiththeuseofanticoagulanttherapy.Use
approvedprotocols(foundonthesharepoint);forpatientsreceivingwarfarinacurrentINRisavailableand
usedtomonitorandadjusttherapy;followwrittenpolicy;provideeducation;anduseprogrammableinfusion
pumpsinordertoprovideconsistentandaccuratedosingofheparin.
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NPSG7:REDUCETHERISKOFHEALTHCAREASSOCIATEDINFECTIONS
ComplywithcurrentWorldHealthOrganizationorCentersforDiseaseControlhandhygiene
guidelines.
Allstaffpracticeproperhandwashinganduseofhandgel(Purell).
Implementevidencebasedpracticestopreventhealthcareassociatedinfectionsduetomultidrug
resistantorganisms(InfectionControlmeasures).
Implementbestpracticestopreventcentrallineassociatedbloodstreaminfections(InfectionControl
measures).
Preventsurgicalsiteinfections(InfectionControlmeasures).
NPSG8:ACCURATELLYANDCOMPLETELYRECONCILEMEDICATIONSACROSSCONTINUUMOFCARE
Aprocessexistsforcomparingthepatientscurrentmedicationswiththoseorderedwhileunderthe
careoftheorganization.
Printoutthe508(CHCS)andhavethepatientannotateanyoverthecounteror
othermedsnotlisted,thenproviderwillgooverthecompletelistwiththepatientandaddanyadditional
medstobegiventothepatient.
Patientwillbegiventhecompletelistofreconciledmedswhendepartingthe
facility.
Alsoifapatientistransferredthecompletereconciledlistisprovidedtothenextprovider.
NPSG9:REDUCETHERISKOFPATIENTHARMFROMFALLS
Implement
afall
reduction
program.
Inpatients
are
assessed
for
falls
risk
at
each
shift.
If
patient
is
identifiedasbeingafallrisk,ayellowwristbandisplacedonthepatient.
NPSG13:ENCOURAGEPATIENTINVOLVEMENTINCARE
Asapatientsafetystrategy,wearetoencouragepatientstobeinvolvedintheircare.
Encourage
patientstoreportanysafetyissuestheyseeinthefacility.Wehaveapatienttrifoldthateducatespatients
onthepatientsafetystrategieswehaveimplementedinthefacility.
NPSG15:IDENTIFYSAFETYRISKSINHERENTINOURPATIENTPOPULATION
Weidentifypatientsatriskforsuicide.Weprovideinformationsuchasacrisishotline18002738255.
NPSG16:IMPROVERECOGNITIONANDREPONSETOCHANGESINPATIENTSCONDITION
Wearetoselectasuitablemethodthatenableshealthcarestaffmemberstodirectlyrequest
additionalassistancefromspeciallytrainedindividuals.
OurmethodistheRapidResponseTeam(RRT). Adult
RRTmembersincludeMOD,ICURN,RespiratoryTherapy,andNursingSupervisor;PediatricRRTmembers
includePOD,RespiratoryTherapy,AssignedRN,NursingSupervisor,andStaff,andPediatricianduringnormal
dutyhours.TheRRTisaninpatientfunctionandcriteriaforcallingaRRTcanbefoundonpostershangingin
theinpatientareas.
UNIVERALPROTOCOL
Conduct
a
pre
operative
verification
process
verify
the
correct
person,
correct
site,
and
correct
procedure; ensureallrelevantdocumentationanditemsareavailable:
H&P,assessments,signedconsent
form,diagnosticandradiologytestresults,andanyrequiredbloodproducts,implants,devicesandspecial
equipmentneededforprocedure.
Marktheproceduresitemarkingtheproceduresiteallowsstafftoidentifywithoutambiguitythe
intendedsitefortheprocedureandifpatientrefusestobemarked,useanalternativemarkingband.
Conductatimeoutimmediatelybeforestartingtheprocedureeachteammemberwillpauseand
verballyconfirmcorrectpatientidentification,agreeonproceduretobedone,correctsiteandsideare
marked,andrelevantdocumentation,imagesandresultsareavailable.
