1. 2016
Patient Safety Goals
San Diego Service Area

2. Use at Least Two Patient Identifiers
Name & MRN WHEN
Administering meds, blood, or blood components
Transfusions require 2 person check
Collecting blood samples & other specimens
Label containers used for blood & other specimens in the presence of the pt.
Providing other treatments or procedures

3. Eliminate Transfusion Errors
Before initiating a blood or blood component transfusion:
Match the blood or blood component to the order
Match the patient to the blood or blood component
Patient identifiers: two licensed individuals (RN, LVN, MD, CRNA, etc.) must positively identify blood products
with patient’s name and medical record number as
printed on the patient’s ID band in the presence of the
patient.
Check the blood against tag on unit for patient's name, medical record number, group and type of blood, number of unit and date of expiration.
RN enters second verifier’s name into Health Connect prior to transfusion
Any discrepancies Stop - send unit back to Blood Bank

4. Improve the Effectiveness of Communication among Caregivers
Verbal Orders & Test Results
Write down (pull up from computer screen) orders/results
Read them back to the person providing them
Get confirmation from the person
Critical Tests & Results
Communicate results ASAP to Provider
Document TIME of notification
Provider must respond to values within ONE hr.
Escalate if response is not received in timely manner when paging Provider to give results

5. Improve the Effectiveness of Communication among Caregivers
Follow Hand-off Communications
Must include opportunity to ask & respond to questions
Use SBAR whenever possible
Review anything pertinent to pt’s care
Give next caregiver a better idea of what to expect
Teamwork
Patient & nursing personnel at ease
Does not replace written report or physical assessment of the pt.
SBAR – Situational Briefing
Situation – State the problem clear and concise
Background – Provide Info that is brief and to the point
Assessment – What do you think/know
Recommendation – Proposed action (What do you want & when)

6. Improve the Effectiveness of Communication among Caregivers: Do Not Use/Accept Abbreviation List
Potential Problem
Use Instead
U, u (unit)
Mistaken for “0” (zero), the number “4” (four) or “cc”
Write (or accept order) "unit"
IU (International Unit)
Mistaken for IV (intravenous) or the number 10 (ten)
Write (or accept order) "International Unit"
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d, qod
(every other day)
Mistaken for each other
Period after the Q mistaken for "I" and the "O" mistaken for "I
Write (or accept order) "daily"
Write (or accept order) "every other day"
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
Decimal point is missed
Write (or accept order)
X mg
Write 0.X mg MS
MSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate
Confused for one another
Write (or accept order)"morphine sulfate"
Write "magnesium sulfate"
Joint Commission, 2004

7. 7 RIGHTS of Medication Safety
RIGHT Patient (2-identifiers!)
RIGHT Route
RIGHT Dose
RIGHT Time
RIGHT Medication
RIGHT Reason
RIGHT Documentation

8. Improve the Safety of Medication Use
Be familiar with steps to prevent errors due to look- alike/sound-alike meds & high alert meds
Be AWARE of look-alike/sound-alike medications
Be AWARE of high alert medications
Label all meds/solutions containers on & off sterile field
Review safety measures for anticoagulation therapy
Properly Label & dispose Multi-dose & Single-use vials
Be familiar with Black Box Warnings
Practice the 7 Rights of medication safety

9. LABEL Requirements
Labeling MUST occur when any med or solution is transferred from the original package to another container
Name of drug/solution
Strength of medication
Amount
Expiration Date: 28 days
Initials of preparer

10. Look-Alike Sound-Alike Medications
General Recommendations
Verbal & phone orders are
Discouraged unless truly necessary
Must be read-back per required verbal order procedure
Products are NOT stored next to each other in pharmacies, pt. care units, clinics, & pt. homes
Report errors or potentially hazardous conditions by completing a UOR
Assure meds are clearly labeled

11. High Alert Medications: Safety Practices
Independent Double Check - Performed independently by two qualified
licensed practitioners
Right Pt identification using two identifiers (name, MRN)
Right Drug
Right Dose, Right Route & Time of administration
Verify setting, rate on IV pump (use guardian mode)
Document on the MAR & Health Connect
Time Out – a period of time immediately before administration /procedure when two qualified practitioners, at pt’s side,
Check special equipment or requirements
Correct pt identity, side/site, pt. position
Agreement on the med administration/procedure with pt./family
Document Time Out on medical record
Medication Safety Verification Record – documentation tool to record Independent Double Checks & Time Outs
Hand-off – an interactive process of passing pt. specific info from one caregiver to another

12. Improve the Effectiveness of Communication among Caregivers
Follow Hand-off Communications
Must include opportunity to ask & respond to questions
Use SBAR whenever possible
Review anything pertinent to pt’s care
Give next caregiver a better idea of what to expect
Teamwork
Patient & nursing personnel at ease
Does not replace written report or physical assessment of the pt.
SBAR – Situational Briefing
S Situation
B Background
A Assessment
R Recommendation (or Request)

13. Anticoagulation Therapy Safety
Pts. on warfarin receive baseline International Normalized Ration (INR) to monitor & adjust therapy
IV Heparin is administered using an IV pump
Independent Double Check required for IV Heparin – before start, with each change of container or rate, & at change of shift hand- offs
Document “Double Check Required” on the eMAR (Health Connect)
Baseline & ongoing lab tests required for heparin therapies
Pt./Family Education
Follow-up monitoring
Compliance
Dietary restrictions
Potential adverse drug reactions & interactions

14. Specimen Equipment and Supplies
Obtain containers, labels, requisition forms, and the preservative or fixative appropriate for the type of testing or delivery.
Collection containers must be impervious
and of an adequate size to easily contain
a specimen
Sterile receptacles and equipment must be used for specimens when sterility must be maintained

15. Identify patient using two verifiers: Verify with specimen collector
Specimen Labeling
Identify patient using two verifiers:
Name
Medical Record Number
Verify with specimen collector
Source/site of specimen
Name of test to be done
Timing of test: Routine or Stat

16. Specimen Labeling Key Steps:
The specimen label is applied by the collector or clinical
support staff witnessing the collection
Label any specimen collected in the back office in the
presence of the patient
Unlabeled specimens cannot be removed from the
collection area (e.g. exam room) to another area for
labeling
Labels may be printed or handwritten
Handwritten labels must be legible and written in black
ink

17. Requisition/Transmittal Slip and Label Criteria
Reacquisition/Transmittal Slip must contain:
Full name, MR number,
Date, time of collection,
Specimen source/type, name of the collector, clinical staff
Initials.
Use pencil to label slides and slides must contain the patient’s
complete name and MRN
Label is placed on each specimen container and NOT on the
lid or transport bag
Unlabeled or mislabeled specimens will not be tested
unless they meet the “exceptions list criteria”
e.g. .body fluids other than blood or urine, tissue, bone
marrow, blood for drug levels, blood cultures, specimens)

18. Chain of Custody
Establish mechanisms for chain of custody to ensure accountability
Complete transmittal slip and send with
specimen to lab
Consistent communication patterns should be established between personnel at change of shift or relief

19. Multi Dose Vials Proper Labeling & Disposal
Write date 28 days from initial opening
Discard on 28th day or if sterility compromised
Examine vial for visible signs of contamination or deterioration
Write date 28 days from initial
opening
Withdrawals from vial MUST
Use sterile technique
DO NOT leave needle or needle
Multidose Vial Adapter Good for 24hrs only
sheath in the vial top for ease of access!

20. Single- dose vials are meant for ONE time use ONLY!
Proper Labeling & Disposal
Contain ONLY ONE dose of
medication, use ONCE & DISCARD after use!
Check mfr. exp. Date BEFORE use
DO NOT use SINGLE-use vials as
Single- dose vials are meant for ONE time use ONLY!
MULTI-dose vials!
All withdrawals require sterile technique

21. Black Box Warnings Emphasize the potential health risk of a drug
FDA requires drugs with serious, life-threatening side effects, or there are more risks than most other prescription drugs carry a black box warning!
Black box warnings have a heavy bold line or box around the warning.
These drugs are effective, although high risk, its benefits outweigh the risks.
KP HealthConnect provides a hyperlink that links to drug information – this is where the Black Box warning will appear.
Contact Pharmacy for questions.
box
Black Box Warning

22. Accurately & Completely Reconcile Medications Across the Continuum of Care
All pt’s must have complete list of current meds, including herbal remedies, vitamins, OTCs, etc., as part of initial assessment
Medication reconciliation must be complete at every visit
Medication reconciliation must occur whenever a pt. is
transferred or there is a change in the level of care

23. Reduce the Risk of Health Care Associated Infections
Wash hands for 15 seconds when visibly soiled or contaminated, otherwise use waterless gel, alcohol based hand rub
Keep nails short and clean
Use only approved lotion
Wear gloves – Latex-free
 Decontaminate hands BEFORE
Contact w/pt’s
Donning sterile gloves
 Decontaminate hands AFTER
Contact with pt. & objects close to pt.
Removing gloves
Taking a break
 Prevent surgical site infections: Use appropriate sterile/aseptic technique, wash hands, use electric clipper for hair preps 
Prevent indwelling catheter-associated urinary tract infections
Secure catheters for unobstructed urine flow and drainage
Maintaining the sterility of the urine collection system

24. Reduce the Risk of Health Care Associated Infections
Be AWARE!
WASH with CARE!
WET hands with water
Apply hand wash – 1 pump
Lather & Wash – 15 seconds
Rinse both sides of hands with water
Dry hands
Shut off faucet with hand towel

25. Follow the Universal Protocol
Conduct pre-procedure verification process
Involve patient, verify consent for procedure
Check for correct patient, site, procedure
Mark procedure site – done by licensed practitioner performing procedure
“X” marks the site!
TIME-OUT performed prior to starting procedures
 DOCUMENT Universal Protocol & Time-out

26. Improve the Safety of Clinical Alarms
Clinical alarm systems are intended to alert caregivers of potential patient problems, but if they are not properly
managed, they can compromise patient safety. This is a multifaceted problem. In some situations, individual alarm signals are difficult to detect.
Many patient care areas have numerous alarm signals and the resulting noise and displayed information tends to desensitize staff and cause them to miss or ignore alarm signals or even disable them.
Monitor and respond to alarms. Do not turn off alarms unless you have authority to do so.

27. Identify patients at Risk for Suicide
Suicide of a patient while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event.
Identification of individuals at risk for suicide while under the care of or following discharge from a health care
organization is an important step in protecting these at- risk individuals.
Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
2. Address the patient’s immediate safety needs and most
appropriate setting for treatment.
3. When a patient at risk for suicide leaves the care of the
hospital, provide suicide prevention information (such
as a crisis hotline) to the patient and his or her family.