Recommended by the Sentinel Event Alert Advisory Group NATIONAL PATIENT SAFETY GOALS FY 2008

NATIONAL PATIENT SAFETY GOALS FY 2008 Patient Identification Improve Accuracy of Patient Identification Communication Improve Effective Communication Among Caregivers Medications Improve Safety of Using Medications Health Care-Associated Infections Reduce Risk of Health Care-Associated Infections Reconcile Medications Accurately and Completely Reconcile Medications Across Continuum of Care

NATIONAL PATIENT SAFETY GOALS FY 2008 Falls Reduce the Risk of Patient Harm Resulting from Falls Patient’s Active Involvement Encourage Patient’s Active Involvement in Their Own Care as a Patient Safety Strategy Organization Identifies Safety Risks Inherent in its Patient Population The Organization Identifies Safety Risks Inherent in its Patient Population

NATIONAL PATIENT SAFETY GOALS FY 2008 Influenza Pneumococcal Disease Reduce the Risk of Influenza and Pneumococcal Disease in Institutionalized Older Adults Health Care-Associated Pressure Ulcers Prevent Health Care-Associated Pressure Ulcers

NATIONAL PATIENT SAFETY GOALS FY 2008 Health Care Organizations are required to demonstrate how the organization is meeting the patient Safety Goals. This CBL will explain the compliance requirements for each of the Safety Goals.

Improve the Accuracy of Patient Identification GOAL 1: Improve the Accuracy of Patient Identification A) Use at least two patient identifiers (not the patient’s room number) when: Administering medications or blood products Taking blood (or other) samples for clinical testing Providing care, treatment, procedure, or services

Identifiers that may be used: The patient’s name Patient’s birth date Assigned identification number Patient’s Social Security number Patient’s telephone number or address Bar coding (includes two or more indicators) Photo ID Improve the Accuracy of Patient Identification GOAL 1: Improve the Accuracy of Patient Identification

Identifiers used for unconscious patient: Family may verify the patient ID EMS/ Police verify the patient ID Assign John/Jane Doe Improve the Accuracy of Patient Identification GOAL 1: Improve the Accuracy of Patient Identification

B) JCAHO requires three items be verified prior to the start of any invasive or surgical procedure: time out Conduct a final verification process such as “time out” to confirm: correct patient correct procedure correct site Improve the Accuracy of Patient Identification GOAL 1: Improve the Accuracy of Patient Identification

Must use ‘active’ communication techniques by all team members Definition of ‘active’ communication: Affirmation - orally or by some action Involves everyone’s participation Improve the Accuracy of Patient Identification GOAL 1: Improve the Accuracy of Patient Identification

GOAL 2: Improve Effectiveness of Communication Among Caregivers read back A) Implement a process for taking verbal or telephone orders that requires a verification “read back” of the complete order by the person receiving the order.

Write purpose of the medication Implement policy for verbal or telephone orders Provide generic and brand names on all medication labels Provide patient written information about their drugs GOAL 2: Improve Effectiveness of Communication Among Caregivers

Record verbal/phone order directly onto order sheet in patient’s chart Read back order to the prescriber GOAL 2: Improve Effectiveness of Communication Among Caregivers

Verbal orders must contain: Patient’s name Medication specifics: 1. Name of drug 2. Dose 3. Route 4. Frequency 5. Duration (if applicable) 6. Purpose of medication (if given as prn) 7. Any additional instructions GOAL 2: Improve Effectiveness of Communication Among Caregivers

B) Standardize the abbreviations used throughout the organization, including a list of abbreviations, acronyms and symbols not to use

DO NOT USE… U Unit IU International Unit MS Morphine Sulfate MgSO Magnesium Sulfate MSO Morphine Sulfate QD Every Day QOD or qod Every Other Day X.0 mg (trailing zero) X mg.X mg (leading zero) X mg GOAL 2: Improve Effectiveness of Communication Among Caregivers Correct Way to Write…

Notify the nurse if you see unapproved abbreviations in use- Do Not Use Abbreviations The “Do Not Use Abbreviations” list is printed at the top of the MD Order Sheets. GOAL 2: Improve Effectiveness of Communication Among Caregivers

critical test results and values C) Measure, assess, and if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values

D) All values defined as “critical” by the laboratory are reported directly to a responsible licensed caregiver within timeframes established by the organization. When the patient’s responsible licensed caregiver is not available within the timeframes, there is a mechanism to report the critical information to an alternate caregiver. GOAL 2: Improve Effectiveness of Communication Among Caregivers

hand off E) Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

GOAL 3: Improve the Safety of Using Medications A) Standardize and limit drug concentrations available in the organization

B) Identify and, at a minimum, annually review a list of look-alike, sound-alike drugs used in the organization, and to take action to prevent errors involving the interchange of these drugs GOAL 3: Improve the Safety of Using Medications

C) Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field in perioperative and other procedural settings. GOAL 3: Improve the Safety of Using Medications

GOAL 4: Reduce the Risk of HealthCare-Associated Infections Comply with current CDC hand-hygiene guidelines (contained within Infection Control CBL) Manage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a health care-associated infection.

A) Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. GOAL 5: Accurately and Completely Reconcile Medications Across the Continuum of Care

B) A complete list of the patient’s medication is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization. GOAL 5: Accurately and Completely Reconcile Medications Across the Continuum of Care

The complete list of medications is also provided to the patient on discharge from the facility. C)

GOAL 5: Accurately and Completely Reconcile Medications Across the Continuum of Care Completion of a Computer-Based Learning Program devoted to the Medication Reconciliation process will be required of staff who are responsible for administration of medications.

A) Assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks GOAL 6 Reduce the Risk of Patient Harm Resulting from Falls GOAL 6: Reduce the Risk of Patient Harm Resulting from Falls

B) Implement a fall reduction program, including a transfer protocol, and evaluate the effectiveness of this program GOAL 6: Reduce the Risk of Patient Harm Resulting from Falls

Define and communicate the means for patients and their families to report concerns about safety, and encourage them to do so. GOAL 7: Encourage Patient’s Active Involvement in Their Own Care as a Patient Safety Strategy

risk for suicide The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.] GOAL 8: The Organization Identifies Safety Risks Inherent in its Patient Population

GOAL 9: Reduce the Risk of Influenza & Pneumococcal Disease in Institutionalized Older Adults Goal #9 pertains specifically to the following populations: a.) Assisted Living b.) Disease-Specific Care c.) Long Term Care

A) Develop and implement a protocol for administration and documentation of the flu vaccine B) Develop and implement a protocol for administration and documentation of the pneumococcus vaccine GOAL 9: Reduce the Risk of Influenza & Pneumococcal Disease in Institutionalized Older Adults

C) Develop and implement a protocol to identify new cases of influenza and to manage an outbreak GOAL 9: Reduce the Risk of Influenza & Pneumococcal Disease in Institutionalized Older Adults

GOAL 10 : Prevent Health Care-Associated Pressure Ulcers Most pressure ulcers can be prevented. Deterioration at Stage 1 can be halted. Teach staff to reduce incidence. Assess patients using Braden Scale to identify patients at risk and provide nutritional support when needed. Increase activity and mobility of patients. Reposition patients while avoiding shear and friction injury.

GOAL 11: Reduce the Risk of Surgical Fires Goal #11 pertains to the following settings: a.) Ambulatory Surgery b.) Office-Based Surgery

A) Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen concentration under drapes GOAL 11: Reduce the Risk of Surgical Fires

NATIONAL PATIENT SAFETY GOALS FY 2008 To complete requirements for this course you must now click on the Take Test icon located at the upper left corner of the computer screen.