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11/2005
Patient Safety
You are the key…
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Table of Contents
Topic Page
Patient Safety Program 3 - 4
Risk Management 4 - 6
List of National Patient Safety Goals 7
Goal # 1 8
Goal # 2 9 - 11
Goal # 3 12
Goal # 4 13
Goal # 5 14
Goal #6 15
Goal # 7 16
Quality Initiatives 17 - 18
Patient Safety Structure 19
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Patient Safety at SHANDS
SHANDS Healthcare has an organizational commitment toimproving patient safety and quality. A well designedprogram includes activities that help identify, minimize andprevent health care accidents and incidents (sentinel events)by creating a culture that values safety.
The comprehensive program within SHANDS HealthCareinvolves a wide variety of activities that focus on:
• Patient Satisfaction• Risk Management/Loss Prevention• Environment of Care/Safety Management• Infection Control• Performance Improvement/CQI Activities• Regulatory Compliance/Continuous Survey Readiness• Utilization Management
All of these program components work together to ensureand improve patient, physician, employee and visitor safety.
Key Concepts:
Human error is a reality – placing blame on the individualdoes not correct the systems that allow mistakes to occur
Errors occur because of flawed systems, not individuals.
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Every employee has the ability to identify actual andpotential flaws, or systems failures, that can impact patientsafety. Report all errors or situations that are potentialsafety risks to your supervisor and complete a PatientSafety Report form. At Shands at the University of Florida,there is an electronic version of this form located on theShands intranet web site. In all other locations, the form isprinted and available in all patient care areas.
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No Yes , complete SECTION 8 on the back. Do Not know
Patient Safety Report Form1. Demographic Information
2. Incident/Med Variance and Discovery Dates
3. Incident/Med Variance Information
4. Location of Incident
5. Injury Information
Hospital: UFAGH
Lake ShoreStarke
Live OakShands Rehab
VistaHomeCare
Report #:
Pt Name:last, first
MRN: Birthday: Age: Gender:/ / Male Female
Patient Type: Inpatient Outpatient ED Visitor HomeCare Student Volunteer Other
INPATIENT/OUTPATIENT/ED:
Unit:
Att MD:
VISITOR, HOMECARE, STUDENT, VOLUNTEER
address
phone
Dept/Clinic
Reason for presence in hospitalAdm Date: / /Adm DX:
Date Discovery: / /Date Incident: / /
Time Discovery:
Time Incident:
Describe objectively what happened:
What measure(s) was/were takenfollowing the discovery of this incident?
Was the injury treated?
Room:
: Explain treatment:Was the subject injured?
Unit: Dept/Clinic: Other:
No YesWas the MD notified? No Yes Do Not know
Was the RM notified? NoYes
MD Name:
DateNotified: / / Person rpt to at RM:
7. Type of Incident
Skin IntegrityFallTrmt/Test/Proc VariancePatient ActionPersonal Property Loss/DamageMedication ErrorEquipment/Device RelatedOther
6. Staff Involved/Witnessed
Name:
Title:Dept:
WorkFT PT
New ( 6 mo.)PRN Pool/CSOAgencyFloat
Mgmt Team
How soon was the variance discovered?0-30 min31-60 min
61 min - 6 hrs> 6 hrs
Only complete the section for the specific patient type below:
city state zip code
Go to Section #2.
After choosing the type(s) of Incident, turn over andcomplete the section on back.
Staff Wit or Inv
name
,specify:
{IP} {OP/ED}
ph: (352) 265-8028
or
Status
[Section 9][Section 10]
[Section 14]
[Section 11]
[Section 8]
[Section 12][Section 13]
(Turn Over to Continue)
FT PT
New ( 6 mo.)PRN Pool/CSOAgencyFloat
Mgmt TeamFT PT
New ( 6 mo.)PRN Pool/CSOAgencyFloat
Mgmt Team
1590140Rev 04.03
SHANDSHealthCare
Go to Section #2.
Staff Wit or Inv Staff Wit or Inv
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What Should Be Reported?
• Actual errors – with or without injury• Wrong patient procedures• Medication errors – wrong patient, wrong medication• Falls
• Potential errors or safety risks• Patient equipment issues – malfunctions, defects,
electrical• Unsafe practices – hand hygiene; unattended
housekeeping carts; unlocked medication carts
• Complaints about the quality of care• Threats to litigate/sue• Suspected injuries• Anything out of the ordinary
All patient related events must be reported within 3business days. Immediately notify your supervisor and thencomplete the electronic, or paper form and submit it to theQuality, Accreditation & Licensure Department.
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The National Patient Safety Goals
The National Patient Safety Goals have been in place since2003. Each year, additional goals are added to helphealthcare facilities focus on improving processes that canaffect patient care quality and safety.
The current goals for 2006 address:
1) Improving the accuracy of patient identification.2) Improving the effectiveness of communication among
caregivers.3) Improving the safety of using medications.4) Reduce the risk of health care-associated infections.5) Accurately and completely reconcile medications across
the continuum of care.6) Reduce the risk of patient harm resulting from falls.
\
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Goal #1: Improving the accuracy of patient identification.A. Use two “identifiers” to make sure you have the right patient! For inpatients
this means checking the name and medical record number (or account number)with the armband of the patient EACH TIME they receive medications, haveblood drawn, receive blood/blood products, when collecting specimens forclinical testing or providing any treatments or procedures.
Areas like HomeCare, clinics, or other ambulatory or out-patient settings needto ASK the patient their name and either their date of birth or address andcompare it to printed material to verify their identity.
Compare nameAND medicalrecord number(or AcctNumber) witharmband EACHtime!
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Goal # 2: Improve the effectiveness of communication amongcaregivers. Implement a process for taking verbal or telephone orders orcritical test results, which include a “read back.”
Verbal/Telephone Orders:
( Write it down completely on the physician order sheet or on atelephone/verbal order sticker, or stamp, when the prescriberis giving the order.
( Read back the entire specific order. You must READ theorder as you have WRITTEN it. DO NOT just repeat backwhat was said.Ø Drug name: Spell it back and/or have the prescriber spell it
to youØ Dose: Say back the numbers (one five, rather than fifteen)Ø Read back the route, frequency, and prn indicationsØ Record the prescriber’s name and MD, ARNP, or PA number.
Use Verbal or Telephone Order Labels!( Place on order sheet in patient’s chart( Process through the HIS computer system as with all Verbal
Orders
Example of Verbal Order Label:
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Critical Diagnostic Test Results:
( Write down the critical test result completely on the criticaltest result label.
( Read back the entire test result as you have WRITTEN itdown. DO NOT just repeat back what was said.
Example of Critical Diagnostic Test Results Label:Critical Diagnostic Test Result Communication Patient Name_____________________Date/Time__________________________ MR Number______________________
Diagnostic Test Result(s)
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B. Standardize a list of abbreviations, acronyms or symbols NOTto be used in the organization.
The following list includes the abbreviations that must be banned in all health care facilities.
DO NOT use any of the prohibited abbreviations in medical orders, medication related ENTRIES in the medical record. In
addition, the banned abbreviations may not be used in pre-printed order sets.
NO YES§ “QD” or§ “QOD”
§ “daily” or§ “every other day”
§ “MSO4” or “MS” § “morphine”
§ “MgSO4” § “magnesium sulfate”
§ “u” § units
§ “IU” § International units
§ “.2” § “0.2” – use leading zero
§ “2.0” § “2” – avoid trailing zeros
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C. Implement a standardized approach to “hand-off”communications, including an opportunity to ask and respondto questions.
The purpose of this goal is to ensure the smooth transition ofpatient care between providers and to make sure pertinentinformation about the patient’s care needs is communicated tothe next care provider before that provider assumesresponsibility for the patient.
“Hand-off” communications may occur:
♦ when a patient is transferred from one unit toanother;
♦ during shift changes;♦ when a patient goes to, or returns from, surgery or
other procedural areas;♦ when the attending physician changes;♦ when housestaff rotations occur; or♦ when patient’s are discharged to other health care
facilities (Rehab; Skilled nursing units) or providerssuch as Home Care.
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Goal #3: Improve the safety of using medications.
A. Standardize and limit the number of drug concentrations availablein the organization.
Only set concentrations of drugs are made or purchased(e.g. 10 mcg/ml fentanyl pca).
B. Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take actionto prevent errors involving the interchange of these drugs.
C. Label all medications, medication containers (e.g., syringes,medicine cups, basins), or other solutions on and off thesterile filed in perioperative and other procedural settings.
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Goal #4: Reduce the risk of health care-associatedinfections.
A. Comply with current CDC (Centers for DiseaseControl) hand hygiene guidelines.
1. Wash your hands when they are visibly soiled!
2. Use an alcohol based hand rub to disinfect hands when theyare not visibly soiled.
Note: A CDC recommendation since 2002 states:
Health care personnel should avoid wearing artificialnails and keep natural nails less than one quarter of aninch long if they care for patients at high risk ofacquiring infections.
B. Manage as a sentinel event any identified case ofunanticipated death or major permanent loss of functionassociated with a health care acquired infection.
1. Report any case of unanticipated death or major permanent lossof function associated with a health care acquired infection bycompleting a written, or electronic, Patient Safety Report. (SeeCore Policy - CP1.35)
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Goal #5 Accurately and completely reconcile medicationsacross the continuum of care.
A. During 2005, develop a process for obtainingand documenting a complete list of thepatient’s current medications upon thepatient’s entry to the organization and withthe involvement of the patient.
B. A complete list of the patient’s medicationsis communicated to the next provider ofservices when it refers or transfers apatient to another setting, service,practitioner or level of care within or outsidethe organization.
Admission Note: Current Med list:1. ____2. ____3. ____Information obtained frompatient/family:Name____________________Nurse_____________ Unit____
Reconcile Medication to nextpractitioner or level of care.Nurse_____________ Unit_____Nurse_____________ Unit_____
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Goal #6: Reduce the risk of patient harm resulting fromfalls.
A. Assess and periodically reassess eachpatient’s risk for falling, including thepotential risk associated with the patient’smedication regimen, and take action toaddress any identified risks.
B. Develop and implement a fall reductionprogram and evaluate the effectiveness ofthe program.
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Patient Safety Initiatives
The hospital has implemented a process toimprove the effectiveness of clinical alarm
systems.
A. Implement preventative maintenance and testingof alarms.
B. Assure that alarms are activated with the correct settings and are able to be heard with respect to distance and other noises in the unit.
Know your alarms. Make sure you can hear them.Check equipment alarms frequently to be sure theyhave not been turned off! Know your responsibilitywhen you hear an alarm. Never ignore an alarm, nomatter who you are!
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The Universal Protocol
Use a preoperative verification process such as a checklist beforethe start of surgical or other invasive procedures. ALL participantson the team need to take a “Time Out” and verbally agree on theright patient, right procedure and performing the procedure on theright site. This includes procedures such as ECT, cardiac cath,endoscopy, bronchoscopy, radiology, BMTU and those done in theED or at the bedside, not just in the operating room! All of thesesteps help to ensure the right procedure is done right.
Mark the surgical site and involve the patient in the marking process.
Before we start, let’stake just a “Time-out” to check and besure we have the rightpatient and are doingthe right surgery.
Hum. This isn’t Mr.Allen’s x-ray. I bettercheck the other x-raysagain before we start.
Yes, the surgeryshould be on my lefteye. This one.
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YOU are the KEY to Patient Safety
Quality Processes lead toImproved Outcomes of
Care &PATIENT SAFETY
Patient Satisfaction
Quality Committees - QSEC
Utilization Review
Medication Safety
EOC / Safety Program
Medical StaffInvolvement
Risk Management
Survey Readiness/RegulatoryCompliance
Infection Control
Performance ImprovementInitiatives
Patient Safety
