NORTH AMERICAN SAFETY CHECKLIST – SB 158

Rhonda Anderson, RHIA President Anderson Health Information Systems, Inc. Presented By:

Patient Safety Committee (PSC) The PSC needs NOT be designated since new provision allows for equivalent Similar to the Resident Care Policy & Infection Control Committees (22 CCR, Section 72525) Members are: ◦ Physicians ◦ Nurses ◦ Pharmacists ◦ Administrators

Duties of the Patient Safety Committee (PSC) Review & approve the patient care plan Receive & review reports of defined patient safety Monitor implementation of corrective actions for patient safety events Make recommendations to eliminate future patient safety events Review & revise the patient care plan, at least once a year & update as needed

Preventive Strategies Infection Control ◦ Surveillance program ◦ Development, implementation, evaluation and monitoring of preventive strategies ◦ Inclusion of DPH lists in the facility policies & procedures to spell out diseases & conditions  Healthcare providers and local health officers are required to report to the local health department (See 17 CCR, Section 2500 et seq.; See AFL 09-05, H&S Code )

Preventive Strategies Safety Plan (or equivalent): ◦ Health & Safety of Resident ◦ Reduce, preventable resident safety ◦ Interdisciplinary development, physician, nurses, pharmacists, administrators

Minimum Safety Plan Requirements Development & implementation of reporting system for resident safety events that allow anyone involved to make a report of a resident safety event to the health facility, including but not limited to: ◦ Health care practitioners ◦ Facility employees ◦ Residents ◦ Visitors

Minimum Safety Plan Requirements -2 A process for a team of facility staff to conduct analysis, including, but not limited to: ◦ Root cause analysis of patient safety events ◦ A reporting process that supports and encourages a culture of safety and reporting patient safety events The team shall be composed of the facility’s various categories of healthcare professionals, with appropriate competencies to conduct the required analyses.

Minimum Safety Plan Requirements -3 The minimum safety plan requires a reporting process that supports and encourages a culture of safety and reporting resident safety events. The minimum safety plan requires a process for providing ongoing resident safety training for facility personnel and health care practitioners.

Safety Events Defined 6 categories of adverse events ◦ Surgical ◦ Product/device ◦ Resident protection ◦ Care management ◦ Environmental ◦ Criminal

Product or Device Events Death/serious disability associated with the use of ◦ A contaminated drug, device, or biologic provided by the facility when the contamination is the result of generally detectable contamination in the drug, device, or biologic, regardless of the source of the contamination or the product

Product or Device Events -2 Death/serious disability associated with the use of ◦ A device (including catheter, drain, or other specialized tube, infusion pump, or ventilator) in resident care in which the device is used or functions other than as intended

Product or Device Events -3 Death/serious disability associated with the use of ◦ Intravascular air embolism that occurs while being care for in a facility, excluding deaths associated with neurosurgical procedures known to present a high risk of intravascular air embolism

Resident Protection Events Death/serious disability associated with: ◦ Resident disappearance for more than four hours, excluding events involving adults who have competency or decision-making capacity ◦ A resident suicide or attempted suicide resulting in serious disability while being cared for in a health facility due to resident actions after admission to the health facility, excluding deaths resulting from self-inflicted injuries that were the reason for admission to the health facility.

Case Management Events A resident death or serious disability associated with a medication error, including, but not limited to, an error involving the wrong drug, the wrong dose, the wrong resident, the wrong time, the wrong rate, the wrong preparation, or the wrong route of administration, excluding reasonable differences in clinical judgment on drug selection and dose.

Case Management Events -2 Resident death or serious disability directly related to hypoglycemia, the onset of which occurs while the resident is being cared for in a health facility A Stage 3 or 4 ulcer, acquired after admission to a health facility, excluding progression from Stage 2 to Stage 3 if Stage 2 was recognized upon admission

Facility-wide “Hand Hygiene Program” – H&S Code ) Beginning January 1, 2011, a health facility will be prohibited from using an intravenous connection, epidural connection, or enteral feeding connection that would fit into a connection port other than the type it was intended for, unless an emergency or urgent situation exists and the prohibition impairs the ability to provide health care. (Health & Safety Code § )

Environmental Events A resident death or serious disability associated with an electric shock while being care for in a health facility, excluding events involving planned treatments, such as electric countershock;  Any incident in which in line designated for oxygen or other gas to be delivered to a resident contains the wrong gas or is contaminated by a toxic substance;

Environmental Events -2 A resident death or serious disability associated with a burn incurred from any source while being cared for in a health facility; A resident death associated with a fall while being cared for in a health facility; A resident death or serious disability associated with the use of restraints or bedrails while being cared for in a health facility

Criminal Events Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provided; The abduction of a resident of any age; The sexual assault on a resident within or on the grounds of a health facility; The death or significant injury of a resident or staff member resulting from a physical assault that occurs within or on the grounds of a facility.

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