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Wm. Jennings Bryan Dorn VAMC Patient Safety Training


Patient Safety Training Billie Thompson RN Patient Safety Specialist Velvet Cooper RN Patient Safety Specialist Extensions 6022 or 4037 – PowerPoint PPT presentation

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Title: Wm. Jennings Bryan Dorn VAMC Patient Safety Training

Wm. Jennings Bryan Dorn VAMC Patient Safety
  • Billie Thompson RN Patient Safety Specialist
  • Velvet Cooper RN Patient Safety Specialist
  • Extensions
    6022 or 4037

Patient Safety Is Everyones Job!
  • The goal of the Patient Safety Program is to
    create a Culture of Safety and awareness of
    patient safety issues for all VA Employees,
    Patients and their Families.
  • Focus Systems
  • Non-punitive
  • Open Communication
  • Process changes

What Are Adverse Events?
  • Patient incidents such as
  • Patient falls
  • Medication errors
  • Elopements (high elopement risk patients)
  • Delays in treatment
  • Suicides and attempts
  • Medical errors
  • Close calls (intercepted or resulted in no harm)

What Is A Sentinel Event?
  • -Death or permanent loss of function resulting
    from a medication or other treatment error
  • -Suicide of a patient in a round-the-clock
    setting or within 72 hours of discharge
  • -Surgery on the wrong patient or body part
  • -Unintended retained surgical object
  • -Hemolytic transfusion reaction
  • -Unanticipated death resulting from an health
    care-acquired infection

How Do I Report A Medical Error or Patient Safety
Incidents Occur While Using Equipment
  • 1. Record any settings before disconnecting/turni
    ng off equipment.
  • 2. Save and label all suspect medical equipment,
    attachments, and packing materials (tubing,
    cables, pads, disposables etc.).
  • Remove immediately from service and place in a
    secure location (i.e. locked head nurses
    office). Do not send through normal channels for
  • Report incident and equipment involved to the
    Patient Safety Officer (ext 6022) and Biomedical
    Engineer (ext 7582) as soon as possible.
  • 5. Enter electronic work order describing the
    incident and Biomedical staff will pick up and
    secure devices until appropriate testing can be
  • 6. Notify VA Police (6804) to pick up and secure
    equipment attachments during non-administrative
    hours as needed.
  • 7. Initiate a VA Form 10-2633, Report of Special
    Incident Involving A Beneficiary displayed on
    next slide.

(No Transcript)
How Do We Investigate Patient Incidents Close
  • A Root Cause Analysis (RCA) team is initiated to
  • What happened?
  • Why?
  • How to prevent it from happening in the
  • An RCA is a process designed to examine the
    systems vulnerabilities to prevent adverse
  • non-punitive
  • multidisciplinary team approach
  • process for identifying basic or contributing
  • process for identifying what we can do to prevent

What Is An Intentional Unsafe Act?
  • An adverse event that results from
  • criminal act
  • purposefully unsafe act
  • alcohol or substance abuse
  • impaired provider/staff
  • alleged patient abuse
  • Intentional unsafe acts should be reported to
    your supervisor and Quality Management
  • Intentional Unsafe Acts are investigated by

What Is A HFMEA?
  • HFMEA or Health Care Failure Mode and Effects
    Analysis (HFMEA) is a proactive risk assessment
    used to identify and correct process problems
    before they happen
  • JCAHO requires a minimum of one HFMEA every 18
    months on a process related to all levels of care
  • 2009 HFMEA Topic Case Management
  • 2008 HFMEA Topic Hand-Off Communication

National Patient Safety Goals 2010
  • -Improve COMMUNICATION among caregivers
  • -Reduce risk of HEALTH CARE-ASSOCIATED
  • -Reduce the risk of patient HARM resulting from
  • -Promote Flu Pneumonia VACCINES
  • -Encourage PATIENT INVOLVEMENT in their care,
  • we are doing to make them safe how to
    report concerns
  • -Prevent nosocomial PRESSURE ULCERS

Improve Patient Safety through Positive
  • Ask the patient or representative to state the
    patients full name full social security number
    or date of birth (two identifiers)
  • Verify the patients correct identification using
    VIC card, Picture ID or ID band
  • Accessing patient information
  • Checking patients in for care
  • Applying a patient ID band two person check
  • Giving medications or blood
  • Providing treatments
  • Performing procedures
  • Drawing blood
  • Obtaining other specimens
  • Labeling specimens - always in the presence of
    the pt.
  • Writing orders
  • Documenting in the patient record
  • I
  • Never use room numbers!

Improve Communication Among Caregivers
  • DO NOT USE VERBAL ORDERS except in emergencies,
    when the physician/provider is NOT present in the
    medical center or is scrubbed in the Operating
  • When taking Verbal or telephone orders always
  • Write it down in CPRS (verbal/telephone order)
  • Read it back
  • Confirm/verify the order with provider
  • Provider signs order in CPRS within 24 hours

  • DO NOT USE the following unacceptable
    abbreviations in any documentation , i.e.
    medication orders, progress notes regarding
    medications in CPRS or paper records.

  • Report critical test test results/critical
    values ONLY
  • to the ordering provider/designee
  • Write it down in CPRS
  • Read it back
  • Confirm/verify the result with provider
  • Provider acts on and documents in CPRS
  • Critical tests Troponins and frozen sections
  • Measure, assess, and take action to improve
    timeliness of reporting and receipt of critical
    test results and values by responsible licensed

Improve Hand-Off Communications
  • Use I-SHARE to remember what information should
    be communicated provide an opportunity to ask
  • When?
  • Changing shifts, providers, caregivers, transfer
    and discharge if provider relationship is known
  • I Identification Identify Patient
  • S Situation Describe Situation/Clinical
    Status/ Code Status
  • H History Background information/Current
  • A Assessment - Most recent clinical findings
  • R Recommendation STAT Orders,
    Plan/treatments needed
  • E Equipment Devices needed/Settings

Patient Hand-off Communication
Avoid Medication Errors
  • LASA Look Alike/Sound Alike Medications
  • To Avoid Errors Double Check Labels Carefully
  • Reminders
  • TALL MAN lettering
  • Blue strip at top of orders in CPRS
  • High alert stickers on medications
  • Colored bins
  • Segregated
  • BCMA
  • Know the High Alert Look Alike Sound Alike
    Medication List - MCM 544-314-1

Label All Medications
  • Includes medication containers (e.g.,
    syringes, medicine cups, basins), or other
    solutions on and off the sterile field in
    operative and other procedural settings. This
    applies to ALL medications
  • Drug name
  • Strength
  • Amount (if not apparent from the container)
  • Expiration date when not used within 24 hours
  • Expiration time when expiration occurs in less
    than 24 hours.
  • Only Exception Same person prepares and
    administers medication immediately one medication
    at a time.
  • When the person preparing the medication is not
    the person who will be administering it, VERIFY
    both verbally and visually with a second
    qualified individual.

Reduce the likelihood of patient harm Associated
with Anticoagulation therapy
  • Weight based heparin protocol
  • Low-molecular weight heparin protocol
  • Heparin order sets in CPRS
  • Heparin therapy nursing note
  • Anticoagulants (IV oral) are designated as
    High Alert
  • Pharmacist on inpt units to monitor
  • Standardized doses for heparin low-molecular
  • Patient education (Coumadin booklets available)
  • Mandatory training in LMS for all clinical staff

Universal Protocol for Ensuring Correct Site
  • 1. Conduct a pre-procedure verification process
    to ensure all documents and related information
    are available before the start of the procedure
    using the Correct Site Checklist
  • Correct Identifiers and labels
  • Patient two identifiers match documents
  • Procedure and site consistent with the patients
    expectations the team members
  • understanding of the intended
  • patient, procedure and site

Universal Protocol for Ensuring Correct Site

2. Mark the procedure site to identify without
ambiguity the intended site for the procedure
for all procedures that require a consent Who?
The provider performing the procedure with
patient involvement When? Before the
patient is moved to location where
procedure will be performed Where? At or near
the procedure or incision site How? Provider
writes initials with permanent marker For
spinal procedures, the provider initials at the
exact vertebral Exceptions Cases where it is
technically or anatomically impossible or
impractical i.e. mucosal surfaces, perineum
Universal Protocol for Ensuring Correct Site
  • 3. Time Out immediately prior to incision,
    ideally before the patient receives anesthesia
    unless contraindicated.
  • A designated member of the procedural team (or
    provider if no assistant required) initiates the
    time out and confirm
  • All team members name and role
  • Correct patient identity using full name and SSN
  • Correct site is marked Consent is accurate
  • Agreement on the procedure to be done
  • Correct patient position
  • History and physical, nursing assessment, and
    pre-anesthesia assessment match consent for
    correct patient, site procedure
  • Correct diagnostic and radiology test results
    (i.e. radiology images and scans, or pathology
    and biopsy reports) that are properly labeled and
  • Ensure any required blood products, implants,
    devices and/or special equipment are available
    for the procedure.
  • Need for antibiotics or fluids for irrigation
  • Safety precautions based on patient history,
    medication use and equipment
  • Correct Site Checklist must be completed and
    signed as indicated on the form and scanned into
    the medical record after the procedure.

Correct Site Checklist Step One
Checked by
Time Name of Procedure(s)_______________________
____________________________________________ Cons
ent obtained, including site/side/name of
___________ _______ ________
reason for procedure No
abbreviations on form Should be completed prior
to transport to Holding Area In Holding
Area/procedure area, physician marks procedure
site with initials must be ___________
_______ ________ a member
of the operating team assigned and consented by
the patient to be present during the procedure
must include patient involvement If step one
not completed, explain reason Step
Two Patient states name/full SS/ location of
body procedure to _____________
_______ ________ be performed. These
responses must be checked by the circulating
staff nurse against consent form/marked site/ID
band Patient must state, not confirm by being
asked. If patient unable and no next of kin
available, 2 staff members will verify and sign.
The Verifying nurse at this point must not leave
the patient. This is the nurse that will be
present during the procedure and again verify the
patients identity during the time-out.a
requirement from the OIG report If step two not
completed prior to transport to the Operating
Room, explain reason Step Three If
applicable, verification by 2 Signatures of 2
physicians physician OR team members (1 must be
an attending) prior to start of procedure that
imaging data is _________________________________
Time ___________ available on correct patient,
properly labeled and properly presented
__________________ Time Out in OR prior
to OR Team Verbal Confirmation signed by
circulating nurse incision OR team (minimum
of indicating name of other team members
surgeon, circulating nurse, anesthesia provider)
verifies Surgeon __________________________Time
_________ name of patient/procedure to be
performed/site, including side/ Anesthesia
______________________________________ implant
specifications and availability, and antibiotic
administered if ordered. Circulating Nurse
_________________________________ Patient
Identification Time
out procedures must be observed by all members of
the operating team. Failure on any team
members part to follow will result in
documentation of non-compliance.
Full Name Full SSN
Reduce Healthcare Acquired Infections
  • Comply with current CDC Hand
  • Hygiene Guidelines.
  • Manage unanticipated death or major
  • permanent loss of function associated
  • with a health care-associated infection
  • as a sentinel event.

Hand Hygiene Is
  • The 1 way to STOP transmission of infection!
  • CDC estimates 30,000 deaths per year being a
    direct result of improper hand hygiene.
  • Statistics indicate that 40 of healthcare
    workers comply with hand hygiene!

Prevent Flu Pneumonia
Why me?
  • Protect yourself..get immunized!
  • Protect your patients.
  • DID YOU KNOW.. With flu you are contagious 24
    hours before you even know you are sick!
  • DID YOU KNOW.Hospitals with high employee flu
    vaccination rates have lower patient mortality!
  • Protect your families dont take germs home!

Medication Reconciliation Process
  • The Provider
  • Develops complete/accurate list of patients
    medication with the patient /or caregiver
  • Compares (reconciles) the list of medications
    with new orders for medications.
  • Updates list as orders change using the
    medication reconciliation note
  • Communicates list to next provider(s) during
  • Provides written discharge instructions with
    medication list to patient
  • The Pharmacist
  • Reviews and compares the current list with orders
    to help
  • avoid duplications, interactions, omissions
    and incorrect doses.
  • Notifies the ordering provider of any
    discrepancies immediately

Reduce Risk of Harm From Falls
  • Hospital falls have a 30 risk of physical
  • At risk populations 1-4 and 85 age groups
  • Increase of injury-related deaths in the elderly
  • Assess Fall Risk using Morse Scale on admission,
    each reassessment, and after a fall
  • Use a Falling Leaf to indicate a patient is a
    high fall risk
  • Implement fall prevention devices, alarms and
  • Correct spills or wet surfaces
  • Dispose of trash appropriately
  • Remove or report any trip hazards and
    environmental hazards immediately
  • Examine for injury before moving the patient
    after a fall
  • Notify the provider
  • Complete Fall Review Note in CPRS notify next
    of kin
  • Implement additional fall precautions as
  • Complete a Post Fall Note within 24 hours after
    the fall

Encourage Active Patient Involvement
  • Encourage active involvement of patients and
    their families in the patient's care as a patient
    safety strategy
  • Inform patients to report any patient safety
    concerns to their provider, nurse or the patient
    representative is necessary
  • Provide Speak Up Booklets with admission
    orientation packets
  • Provide Patient Education Booklets and
    instructions to new veterans and to all
    inpatients and families during orientation
    containing information about how to report
    concerns about safety
  • Check Education Resource Center (PERC) across
    from canteen
  • Provide Joint Commission contact information
  • Joint Commission
  • Complaint Hotline 1-800-994-6610

Prevent Pressure Ulcers
  • 1.3 - 3 Million adults have pressure ulcers
    costing 500- 40,000 per ulcer
  • Identify at risk individuals (Braden Scale)
  • Maintain and improve tissue tolerance
  • to prevent injury
  • Protect against adverse effects of external
    mechanical devices
  • Reduce the incidence of pressure ulcers through
  • Use special mattresses as indicated

Reduce Risk for Suicide.
  • Suicide risk screening to identify individuals at
    risk for suicide while under the care of or
    following discharge is an important step in
    protecting these at-risk individuals.
  • Suicide risk assessments
  • Address the patients immediate safety needs and
    most appropriate setting for treatment.
  • High Risk List Notify Suicide Prevention
  • Provide suicide prevention information on signs,
    symptoms, means reduction, the crisis hotline ,
    etc. to individuals at risk for suicide and their
    family members.
  • Develop a Safety Plan with the patient /or
    family members

Improve Recognition and Response to Changes in a
Patients Condition
  • Goal To mobilize a team at the first sign of
    impending crisis or doom, to reduce failure to
    rescue, improve patient safety, and reduce the
    number of code 5s and medical crises.
  • Rapid Response Team - Code White
  • Team CompositionACLS Nurse, Sr. Resident, Resp.
  • Team Responsibilities- Quick assessment, work
    within protocols, administer treatment,
    stabilize transfer patient as indicated
  • Response Times Established5 minutes
  • Implemented on all inpatient units 12/08

Criteria for Activation of Code White Dial 6555
  • Staff member concerned/worried about the patient
    (i.e. decreased urine output, temperature gt 101,
    or patient diaphoretic)
  • Acute change in heart rate (less than 40 or
    greater than 130)
  • Acute change in systolic blood pressure (less
    than 90 mm/Hg or greater than 170)
  • Acute change in respiratory rate (less than 8 or
    greater than 34) or threatened airway
  • Acute change in oxygen saturation which reflects
    the percentage of red blood cells saturated with
    oxygen (level is less than 90 despite oxygen
    being utilized on the patient)
  • Acute change in level of consciousness
  • Acute significant bleed
  • Patients oxygen requirements increase to 50 or
    greater (normal air breathed is 21 oxygen)
  • New, repeated, or prolonged seizures
  • Failure to respond to treatment for an acute

What Is A Code 5?
  • Code for Medical emergencies such as respiratory,
    cardiac arrest or other situations where someone
    is unresponsive or injured.
  • What is your role in a Code 5?
  • Ask the person Are you OK? and get help
  • Ask someone to call a Code 5 - Dial 6555 state
    the patient location room and get the closest
    AED or Emergency Cart
  • Provide the Code 5 team with a history of events
    leading up to the code or observations, if known.
  • Provide BLS/CPR if you are trained

What Is Disclosure?
  • Telling the patient and or significant family
    members clinically significant facts about the
    occurrence of an adverse event that resulted in
    patient harm, or could result in harm in the
    foreseeable future.
  • Clinical Disclosure is a simple, informal process
    where the provider discloses all adverse events
    that occur in the routine course of medical
    practice even if there was no harm to the
    patient. Documentation of the facts and who was
    informed is the responsibility of the physician
    care for the patient.
  • Institutional Disclosure is a formal process used
    where the Chief of Staff discloses a serious
    adverse events. Disclosure if required within 72
    hours that the physician is aware of the adverse
    event. Documentation in Disclosure of Adverse
    Event Template in CPRS is required.

What Can We Do?
  • Observe your work environment for patient safety
  • Report unsafe conditions medical errors to your
    supervisor and the patient safety officer or the
    Anonymous Incident Reporting Hotline 7964
  • Comply with National Patient Safety Goals
  • Serve on a RCA, Aggregate Review, or HFMEA team
  • ASK your Patient Safety Officer or supervisor

Words of Encouragement
Gentlemen, we are going to relentlessly chase
perfection, knowing full well we will not catch
it, because nothing is perfect. But we are
going to relentlessly chase it, because in the
process we will catch excellence.
I am not remotely interested in just being good.

Vince Lombardi, head coach Green Bay Packers,
1959 1967
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