2009 National Patient Safety Goals Kathleen Killoran, MS, RN-BC Created 8/18/2009 June06

OBJECTIVES Upon completion of this competency, the learner will be able to: Identify the main purpose of the Joint Commission National Patient Safety Goals (NPSGs). Name the three (3) patient identifiers used at AIMMC to promote patient safety. Review the purpose, process and importance of medication reconciliation. Apply each of the National Patient Safety Goals to practice. June06

The purpose of the Joint Commission’s National Patient Safety Goals (NPSGs) is to promote specific improvements in patient safety. June06

GOAL # 1 Improve the Accuracy of Patient Identification We will be moving towards using 3 identifiers Name Medical Record Number Date of Birth You know your patients HOWEVER, we are only human. Therefore; Confirm patient identifiers prior to administering meds, performing ALL procedures or when transporting to other areas, etc. June06

GOAL # 1 Improve the Accuracy of Patient Identification Eliminate transfusion errors related to patient misidentification. FOLLOW TWO PERSON VERIFICATION PROCESS USING THREE IDENTIFIERS AND TWO QUALIFIED ASSOCIATES! June06

IDENTIFICATION OF PATIENTS Patient Safety Question? What are the 3 patient identifiers used at IMMC? June06

IDENTIFICATION OF PATIENTS Patient Safety Answer: The Pt Name, DOB & Medical Record # on the armband June06

Name 3 occasions when you should check the patient’s armband? ARMBANDS Patient Safety Question? Name 3 occasions when you should check the patient’s armband? June06

ARMBANDS Patient Safety Answer: Every time you interact with the patient!!! For example: At the beginning of your shift. Before administering a med. Before administering a blood product. Before performing any procedure. Comparing the chart order before transporting a patient off the unit. June06

GOAL #2 Improve the effectiveness of Communication among Caregivers “Read-back” all verbal orders, telephone orders and critical test results to confirm accuracy. Reporting of critical values in a timely manner. Standardize the abbreviations, acronyms and symbols and eliminate unacceptable abbreviations Implement a standard approach to “Hand off” communications, including an opportunity to ask and respond to questions June06

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What does this say? June06

We have no idea either… June06

Morphine Sulfate or Magnesium Sulfate DANGEROUS ABBREVIATIONS DO NOT USE Ug mcg U unit QD daily cc ml IU International Unit QOD Every other day 5.0 mg 5mg .25 mg 0.25mg SC or SQ SubQ MS MSO4 MgSO4 Morphine Sulfate or Magnesium Sulfate June06

GOAL #2 Improve the effectiveness of Communication among Caregivers cont. Handoff communication: follow the 5 P’s & include time to ask and answer questions Handoff Situations: Nursing or allied health shift to shift report Transfer of care between nurses or allied health to physician transfer of care Clinician providing temporary coverage Interdepartmental handoffs, such as the nursing unit to Imaging, PACU to the nursing unit: RN to complete Hall Pass tool to communicate information to the other caregivers. Transfers of the patient within units of the hospital 5 P’s Patient Plan Purpose Problem Precautions June06

Patient Safety Question? GOAL #2 Improve the effectiveness of Communication among Caregivers cont. Patient Safety Question? What is the process of communicating relevant patient information to another clinician? June06

GOAL #2 Improve the effectiveness of Communication among Caregivers cont. Patient Safety Answer: “Handoff” The RN is responsible for completing the Hall Pass or Patient Transport Tool when the patient leaves the floor June06

GOAL #3 Improve the Safe Use of Medications Remove concentrated electrolytes from patient care areas. Limit the number of drug concentrations. Take action to prevent errors with look-alike/sound alike drugs. Label syringes, cups and containers on procedure trays June06

Goal # 3: Medication Safety Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. Monitor PT/INR when patients are on Coumadin Monitor PTT when patients are receiving IV Heparin Educate patient/family on anticoagulation therapy Individualize care provided to each patient receiving anti-coagulant therapy June06

Goal # 7: Reduce the Risk of Health Care Acquired Infections Comply with Hand-Hygiene Guidelines Hands, wrists, and forearms are washed for at least 15 seconds with soap and water Alcohol hand-rubs are appropriate for rapid hand decontamination between patients when hands are not soiled. Refer to: Hand Hygiene Policy (90.017.038) It is considered a sentinel event if a health care acquired infection (HAI) leads to death or major permanent loss. June06

Goal # 7: Reduce the Risk of Health Care Acquired Infections cont. Implement evidence-based practices to prevent health care acquired infections (HAI) due to multiple drug-resistant organisms (MDRO) in acute care hospitals. Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections, surgical site infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. All associates must be educated annually on MDROs, and HAI infection prevention strategies. June06

Goal # 7: Reduce the Risk of Health Care Acquired Infections cont. Patient Safety Question? What is the #1 safeguard to prevent Health Care Acquired Infections? June06

Goal # 7: Reduce the Risk of Health Care Acquired Infections cont. Patient Safety Answer: Hand Hygiene! See Hand Hygiene Policy (90.017.038) June06

Goal # 7: Reduce the Risk of Health Care Acquired Infections cont. NEW!! We must educate our patients regarding infection prevention strategies. All patients need basic infection prevention education. Isolation patients need isolation and isolatable organism education. Patients with a central line, urinary catheter, ventilator, or surgical site need device/procedure related infection prevention education. Click links for more information or to view available educational materials. Or, go to Advocate Online > Illinois Masonic > Departments > Infection Control & Epidemiology > Associate Education. June06

Goal 8: Accurately and completely reconcile medications across the continuum of care Medication Reconciliation is the process of verifying patient’s medication June06

Goal 8: Accurately and completely reconcile medications across the continuum of care cont. Document a complete list of the patient’s current medications on admission, and compare this to the medications provided by the facility. Communicate this complete list whenever the patient’s care is transferred to anther area, setting, or healthcare provider. June06

Patient Safety Question? Goal 8: Accurately and completely reconcile medications across the continuum of care cont. Patient Safety Question? A nurse entered home medications for a patient based on ER documentation which included lasix and furosemide. The Admitting resident ordered “resume all meds” and both were ordered. What process would have caught this error before it reached the patient? June06

Medication reconciliation Can reduce errors by 46% Goal 8: Accurately and completely reconcile medications across the continuum of care cont. Patient Safety Answer: Medication reconciliation Can reduce errors by 46% Can reduce Adverse Drug effects up to 20% Barnstiener JH. Medication reconciliation: transfer of medication information across settings—keeping it free from error. J Infus Nurs. 2005l28(2 suppl):31-6. Rozich, J, et al. Medication safety: one organization’s approach to the challenge. J Clin Outcomes Manag. 2001;8:27-34. June06

When does Medication Reconciliation need to be done for my patients? Goal 8: Accurately and completely reconcile medications across the continuum of care cont. Patient Safety Question? When does Medication Reconciliation need to be done for my patients? June06

Upon: Admission Transfer(s) 3. Discharge Goal 8: Accurately and completely reconcile medications across the continuum of care cont. Patient Safety Answer: Upon: Admission Transfer(s) (different level of care) 3. Discharge June06

What is the number one nursing liability related to patient safety? Goal 9: Reduce the risk of patient harm resulting from falls Patient Safety Question? What is the number one nursing liability related to patient safety? June06

Patient Safety Answer: Patient falls Goal 9: Reduce the risk of patient harm resulting from falls cont. Patient Safety Answer: Patient falls June06

What are examples of fall risk reduction interventions? Goal 9: Reduce the risk of patient harm resulting from falls cont. Patient Safety Question? What are examples of fall risk reduction interventions? June06

Goal 9: Reduce the risk of patient harm resulting from falls cont. Patient Safety Answer: Purposeful rounding Bed in low position at all times Call light within reach at all times Side rails up X 2 or X 3 if patient is at high risk for falls at all times Proper room lighting Use of bed alarm technology if patient is at high risk for falls Personal items within reach at all times June06

Goal # 13: Encourage Patient’s Active Involvement in Plan of Care Identify the ways in which the patient and his or her family can report concerns about safety and encourage them to do so. June06

Goal # 13: Encourage Patient’s Active Involvement in Plan of Care cont. Communicate expectation that patients and family report safety concerns and encourage reporting Provide basic infection prevention and control education including hand hygiene, respiratory hygiene and contact precautions, as applicable. (For more information, click here.) Provide Surgical Infection, Patient Identification and Surgical Site Marking Educational Materials, as applicable. June06

Goal # 13: Encourage Patient’s Active Involvement in Plan of Care cont. Provide the information to the patient and/or family on the day the patient enters the hospital or within 24 to 48 hours Evaluate and document the patient’s understanding of this information. June06

Goal # 15: Risk for Suicide The organization identifies patients at risk for suicide. All patients presenting at the Emergency Department will be screened by the nurse for suicide risk The admitting RN will ask the suicide screening question on patients Implement Suicide Precautions immediately if the patient is at risk of harming self June06

SUICIDE SCREENING DOCUMENTATION June06

Goal #16: Improve recognition and response to changes in a patient’s condition. The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. At AIMMC, staff can directly request additional help from the Rapid Response Team (RRT), a specially trained team, if the patient’s condition worsens. June06

2009 JCAHO National Patient Safety Goals -&- Universal Protocol # 1 Elimination Wrong Site, Procedure, Person, Surgery Timeouts EVERYONE participates!!! Site Marking June06

What is Advocate’s RED RULE? 2009 JCAHO National Patient Safety Goals cont. Patient Safety Question? ? What is Advocate’s RED RULE? June06

2009 JCAHO National Patient Safety Goals cont. Patient Safety Answer: Time OUT Patient Safety Answer: June06

Universal Protocol, the Three Steps… 2009 JCAHO National Patient Safety Goals cont. Universal Protocol, the Three Steps… Step 1: The preoperative/procedure VERIFICATION process -Correct patient -Correct Procedure -Correct Site Step 2: The operative/procedure site MARKING Step 3: A ‘TIME OUT’ immediately before starting the procedure June06

Marking the site The operating physician/surgeon discusses surgery/procedure with patient, verifies and confirms site with consent form and patient’s statement of planned procedure June06

2009 JCAHO National Patient Safety Goals cont. Don’t forget! The “TIME-OUT process applies to procedures OUTSIDE the OR as well! Rule of thumb: Anything that may require a consent and/or is a “high risk” procedure requires a TIME-OUT June06

PATIENT SAFETY REPORTING Patient Safety Question? What have you done lately for patient safety? June06

PATIENT SAFETY REPORTING Patient Safety Answer: Remember to submit A Patient Safety Event Report via Remote Data Entry (RDE) to identify areas for process improvement. June06

REFERENCES: Click to review Advocate Policy #: 90.017.017: Fall Prevention 90.017.018: Mandatory Time Out 90.017.038 Hand Hygiene Policy Click to review Online Resources: National Patient Safety Goals www.jointcommission.org Patient Education of Infection Prevention Strategies June06

You are now ready to complete the 2009 Joint Commission National Patient Safety Goals Quiz. Click on the Quiz and select the best answers. RNs 80% correct (10/12) is required for successful completion. RNs Click here for quiz. June06