Health Occupation Student Orientation Module 4: Provision of Care

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Health Occupation Student Orientation Module 4
Provision of Care
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PATIENT SAFETY Goals

• Section 1

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Patient Safety Goals / Initiatives

• Background
• Patient Safety Goals were first established in
  2002 by the Joint Commission to help accredited
  hospitals address specific areas of concern in
  regards to patient safety.
• These goals are hospital regulatory requirements
  that must be met. Accreditation surveys evaluate
  hospitals for goal implementation.
• Each year the list of patient safety goals is
  reviewed and updated by a panel of widely
  recognized patient safety experts.
• The following slides describe our practices for
  some of these goals.

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Patient Safety GoalImprove Accuracy of Patient
Identification

• Use 2 Patient Identifiers
• Identifiers - Name and Date of Birth
• Check/scan armband and ask patient to state their
  name
• When to Check Patient Identifiers
• Ordering/delivering meals
• Collecting / labeling specimens
• Administering Medications
• Blood Administration
• Prior to procedures, treatments and transport

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Patient Safety GoalImprove Communication
Physician Orders

• Validate Completeness and Accuracy of Verbal or
  Telephone Orders
• Write Down the order, Read Back the order
• Document as VORB or TORB
• Verbal Med Orders limited to emergencies only e.g
  codes

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Patient Safety GoalImprove Communication
Physician Orders
UNACCEPTABLE ACCEPTABLE
IU Write out the words International units
QD or QOD Write daily or every other day
MS, MS04, MgSO4 Write Morphine Sulfate or Magnesium Sulfate
Use of Trailing zeros (i.e. 5.0mg) Omit trailing zeros (i.e. 5 mg)
Omission of leading zeros (i.e. .5mg) Use leading zeros (i.e. 0.5mg)
U or u Spell out the word units
BIW Write twice a week
DPT Write Demerol-Phenergan-Thorazine
Dram Write Teaspoonful
Minum Write drop

• DO NOT USE Abbreviations shown at right which are
  known to increase risk of errors.
• Physician orders containing an unapproved
  abbreviation must be clarified with the ordering
  physician.

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Patient Safety GoalImprove Communication Hand
Off Report

• Give an Effective Handoff Report
• When To Do a Handoff
• Change of shift transfer to different care unit
  sending patient to diagnostic imaging etc.
• Your Role make sure you give a verbal report to
  the primary RN before leaving each day.
• What To Include in Report
• Patients condition, treatments, medications,
  services, Fall risk, isolation, code status and
  any recent and/or anticipated changes
• Limit interruptions, provide opportunity for
  receiver to ask/respond to questions

An estimated 80 percent of serious medical
errors involve miscommunication between
caregivers when patients are transferred or
handed-off.
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Patient Safety GoalImprove Communication -
Patients

• What Needs Interpreting
• Patient intake
• HP
• Consent
• Discharge instructions
• Who Can Interpret
• Bilingual staff may interpret non-clinical
  information only
• Family members and friends should not be used.
  However, if patient insists, a certified
  interpreter must also be present
• Hospital Approved Interpreters - ask the primary
  RN or Charge RN about these
• Language Barriers Pacific Interpreters
• Hearing Impairment American Sign Language TTY
  and TDD devices available

Patient has the right to make informed decisions
regarding his/her care.
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Patient Safety GoalImprove Communication -
Patients
White Boards Examples of What to Record
Date Nurse Care Partner Doctor Daily
Goals

• Use Patient Staff Communication Boards
• Purpose keep patients informed
• Boards are located in inpatient rooms 1 per
  patient
• Update beginning of shift during handoff report

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Patient Safety GoalImprove Communication -
Patients

• Round on Patients
• When
• Every 1 2 hours
• When providing services
• Accomplish scheduled tasks
• Address 4 Ps (pain, toileting, positioning and
  personal items nearby call light, phone etc)
• Conduct environmental assessment (bed alarms set,
  IV pumps etc)
• Ask Is there anything else I can do for you
  before I go?
• Communicate unmet needs to nursing
• Document the round on the white board

The Four Ps Pain Potty Position Personal
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Patient Safety GoalImprove Communication Among
Caregivers

• Call Critical Test Results Promptly
• Critical (emergent) test results have been
  defined by the lab. These test results include
  critical values for blood glucose testing.
• All critical values must be called to the
  physician within 60 minutes of being resulted.
• Student Role Notify the Primary RN immediately
  if a critical value is obtained when performing
  blood glucose testing.
• Document Date/time of notification Who was
  notified Value reported Readback obtained (RBO)

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Patient Safety GoalImprove Communication Among
Caregivers

• Check Safety Arm Bands look for these high
  alert arm bands
• Applied to same limb exception limb restriction
  applied to affected limb.
• Allergy Band everyone one gets an allergy band!
  If no allergies, write NKA on the band. DO NOT
  list allergies on the band.
• DNR Band optional - patient may decline to wear
  armband. If declined, inform patient that without
  the communication band we may not be able to
  comply with their preferences.
• Document application / removal in nurses notes.

Yellow Fall Risk
Pink Limb Restriction
Red Allergy
Blue Isolation
Purple Do Not Attempt Resuscitation
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Patient Safety GoalImprove Recognition/Response
to Changes in Patient Condition

• Rapid Response Team
• When to Call
  Concern about worsening patient condition
  airway/breathing problems, neuro changes,
  circulation problems
• Student Role
  If possible, check with the primary
  RN or Charge RN immediately for change in patient
  condition before calling RRT.
• How to Call
  Dial 7101 and enter 50.
  State Rapid Response Team to
  _________ and identify location.
• Who Responds
  ICU RN, RT, Admin Sup

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Patient Safety GoalPrevent Hospital Acquired
Conditions

• The Center for Medicare Services (CMS) has
  identified a number of hospital acquired
  conditions that are high cost or high volume or
  both and could reasonably be prevented with
  implementation of evidenced-based practice
  guidelines.
• Occurrence of these conditions can significantly
  impact patient quality of life as well as
  hospital reimbursement for care.
• Current care guidelines are described on the
  following slides.

Hospital Acquired Conditions Pressure
Ulcers Falls Deep Vein Thrombosis
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Patient Safety GoalPrevent Hospital Acquired
Conditions FALLS

• Prevent Patient Falls
• Who Is At Risk patient with
• History of falls
• Unsteady gait poor balance, use of ambulatory
  aid
• Multiple health problems e.g. diabetes, lung
  disease, heart problems
• Mental status overestimates or forgets
  limitations

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Patient Safety GoalPrevent Hospital Acquired
Conditions FALLS

• Standard Interventions for All Patients
• Maintain Safe Environment
• Adequate lighting in room night lite or
  bathroom lite as indicated
• Room Free of Clutter / Obstructions / trip
  hazards
• Bed in low position, wheels locked.
• Call light within reach
• Personal, frequently used objects within reach

• Monitor
• Round Frequently (every 1-2 hours)
• Be Alert - investigate noises in patient areas
• Directly (visual observation) or indirectly
  (within hearing) supervise patient while in
  bathroom
• Other
• Provide non-skid foot ware
• Obtain assist devices normally used by patient.

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Patient Safety GoalPrevent Hospital Acquired
Conditions FALLS

• Interventions for High Risk Patient
• Communicate Risk
• Yellow slippers, armbands and Fall Risk door
  signage
• Implement actions to prevent falls
• Assist out of bed/chair
• Use of mobility devices
• Do not leave patient unattended in bath room
  keep within arms reach
• Use Safety Devices
• Activate Bed alarms verify bed connected to call
  light system and bed alarm activated

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Patient Safety GoalPrevent Hospital Acquired
Conditions Pressure Ulcers

• Prevent Pressure Ulcers
• Who is At Risk patients with
• Limited ability to change or control body
  position
• Inadequate food intake
• Sensory impairment in extremities limited
  responsiveness
• Bed bound or chair bound not ambulating
• Skin frequently moist due to urine or stool

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Patient Safety GoalPrevent Hospital Acquired
Conditions Pressure Ulcers

• Promptly Report to RN
• Observed red/pink areas or skin breakdown
  especially over bony prominences or under devices
  e.g. nasal cannulas, SCDs, anti-embolic hose etc.

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Patient Safety GoalPrevent Hospital Acquired
Conditions Pressure Ulcers

• Preventive Interventions - Save Our Patients Skin

S Surface Keep linen wrinkle free. Check for plastic caps in bed. Monitor for device-related pressure areas e.g. O2 tubing, cervical collars, SCDs, anti-embolic hose. Cushion / protect skin in high risk areas.
K Keep Turning Float heels. Turn, turn, turn.
I Incontinence Offer assistance with toileting. Notify staff if patient incontinent. Use skin cleansers/moisturizers promptly after each episode of incontinence.
N Nutrition Provide assistance with meals. Ensure access to supplements. Accurately document intake and output.
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Patient Safety GoalPrevent Hospital Acquired
Conditions VTE

• What is VTE
• Venous thromboembolism (VTE) is a blood clot that
  forms in the deep veins (DVT), breaks off and
  travels in the veins to the lungs. It can become
  a life-threatening pulmonary embolism (PE).
• Who is at Risk
• Older patient
• Major surgery orthopedic surgery
• Immobility
• Trauma
• Central line
• Obesity
• Positive history for DVT or PE
• If at High Risk
• Sequential Compression Devices (SCDs) If
  ordered, ensure they are correctly applied and
  turned on when in bed and up in chair
• Anti-Embolic Hose if ordered, remove every shift
  x 30 minutes monitor skin for breakdown

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Patient Safety GoalIdentify Patient Safety Risk
- Suicide

• Suicide of a patient while in a staffed,
  round-the-clock care setting is a frequently
  reported type of sentinel event.
• Who is at Risk appropriate patients are assessed
  for mental illness, chemical impairment, suicidal
  ideation or judgment deficits that pose risk of
  harm to self or others.
• Safety Precautions Depending on Assessed Risk
  Level, Precautions May Include
• Frequent close observation sitter if indicated
• Maintain safe environment removal of equipment
  and supplies and objects from patient room that
  could be used for self harm use of plastic
  utensils and paper goods.
• Provide prevention information (crisis hotline)
  at time of discharge.

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Patient Safety GoalPrevent Wrong
Site/Procedure/Person Surgery
The Universal Protocol Elements apply to all
settings including bedside procedures where
consent is required.

• Pre-Procedure Verification verify the following
• Signed consent which matches physician order
• Updated history and physical pre-anesthesia
  assessment
• Diagnostic test results available
• Procedure prep requirements met
• Any required blood products, implants devices
  and/or special equipment available
• SCIP measures met e.g. antibiotics given

• Surgical Site Marking
• Required for all incisions, punctures and
  insertions
• Performed by Surgeon, PAs (SJH only) or
  Proceduralist
• Involves patient
• Permanent marker used to write initials near
  surgical site Visible after draping

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Patient Safety GoalPrevent Wrong
Site/Procedure/Person Surgery

• Procedural Time Out
• Every one participates
• Correct patient, procedure, consent,
• Correct position/site/side visible site mark
• Antibiotics given prep agent and fire risk
  score safety precautions for patient history/med
  use taken
• Relevant images and results
• Implants, blood /blood products and special
  equipment available if applicable

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Recognition / Prevention Malnutrition/Aspiration

• Malnutrition and Aspiration
• Who is at Risk patients are screened on
  admission for the risk factors shown at right.
• Measures to Reduce Risk
• Assist patients with meals as indicated
• Provide / encourage consumption of supplements
  etc.
• Document diet intake if it isnt documented we
  cannot evaluate how are patient is doing.

• Risk Factors
• Unintentional weight loss
• Decreased appetite
• Difficulty eating
• Contributing Minor/Chronic Diseases or Factors
  e.g. renal disease, pressure ulcers,
  tube feeding,

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Infection Recognition - Sepsis/Severe Sepsis

• What is Sepsis
• Sepsis is a potentially life-threatening
  complication of an infection. It occurs when
  chemicals released into the bloodstream to fight
  infection trigger inflammation throughout the
  body. Inflammation can damage multiple organ
  systems, causing them to fail.
• If sepsis progresses to septic shock, blood
  pressure drops dramatically, which may lead to
  death.
• Early recognition and treatment of sepsis is
  essential.
• Sepsis Screening is completed on Admission and
  Every Shift by the RN

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Infection Recognition - Sepsis/Severe Sepsis

• Your Role Promptly report to the RN vital sign
  changes that match sepsis criteria.

SIRS Criteria SIRS 2 or more criteria met SIRS Criteria SIRS 2 or more criteria met
Heart Rate gt/90
Temp /gt38 C or lt 36 C
RR gt/ 20
WBC lt4 gt12 or gt10 bands
Severe Sepsis Criteria Severe Sepsis Criteria
MAP lt 65 mmHg x2
Creatinine gt 2mg/dl
ALOC
SBP lt90 x2
SBP ? 40 mmHg
New or ? O2 Needs
UO lt5mg/kg/hr x gt2 hrs
Bilirubin gt 2mg/dl
INR gt1.5 or PTT gt60 sec
Lactate gt 4 mmol/L
SIRS Systemic Inflammatory Response Syndrome
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Adverse Event Prevention Tubing Misconnections

• The Problem
• The following events were reported by the Food
  and Drug Administration.
• Blood pressure tubing connected to IV line by
  family member patient died.
• IV tubing connected to nasal cannula patient
  went into CHF.
• IV tubing connected to feeding tube by family
  member no harm as identified quickly.
• Feeding tube connected to trach tube patient
  died.
• IV Tubing connected to trach cuff patient died.
• Oxygen tubing attached to IV tubing patient
  died.

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Adverse Event Prevention Tubing Misconnections

• The Solution
• Increase lighting in a darkened room before
  connecting or reconnecting tubes or devices.
• Trace the tube or catheter from the patient to
  point of origin.
• Do NOT force connections
• Never use a standard luer-lock syringe for oral
  medications or enteric feedings use slip tip
  syringe.
• Reconcile lines as part of handoff with change of
  shift, patient transfer, return from procedure.
• Patient / family education DO NOT connect or
  disconnect lines. Get help!

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Adverse Event Prevention
CENTRAL LINE Attach to IV tubing going to CL
PERIPHERAL LINE Attach to IV tubing going to peripheral line
ARTERIAL LINE Attach to IV tubing going to arterial line
ADDITIVE Attach to IV tubing of any IV solution that has med added i.e. NS with KCL
IRRIGATION Attach to irrigation tubing
DRAIN Attach to drain urinary catheter, hemovac, jackson pratt, penrose, NG
ENTERAL FEEDING Attach to formula tubing
FEEDING TUBE Attach to feeding tube G-tube, J-tube, nasal feeding, PEG tube, Keofeed
OTHER

• Use Tubing Labels
• Place label on the tubing adjacent to the
  connection site where tubing connects to
  patient
• Continue to use IV Tubing Change Stickers (Mon,
  Tues etc.)

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RESTRAINTS

• Section 2

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RESTRAINTIndications for Use
Patient behaviors that may lead to the use of
restraints fall into two categories as described
below

• Non Violent Behavior
• Attempting to pull out tubes, drains, or other
  lines medically necessary for treatment and is
  unable to comply with safety instructions
• Attempting to get out of bed and unsteady gait
  at risk of falling and is non compliant with
  safety instructions.

• Violent, Self Destructive Behavior
• Physically assaultive to others or is highly
  agitated and assaultive behavior is pre-eminent
  e.g. Code Grey - type individuals
• Physically harmful to self (i.e. attempting
  suicide, self-mutilation, hurting self, etc.)

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RESTRAINTIndications for Use

• Before restraints can be initiated for these
  patient at-risk behaviors
• Causal Factors are Considered
• Identify medical problems that could be causing
  behavioral changes e.g. increased temp, hypoxia,
  low blood sugar, electrolyte imbalance, drug-drug
  interactions
• Alternatives Considered / Attempted
• Hiding tubes/lines, frequent rounding,
  reorientation, family intervention,
  companionship, mobility, distraction e.g. folding
  wash cloths use of alarm devices
• Physician Order is Obtained only RNs or
  Physicians can initiate use of restraints

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RESTRAINTPlan of Care Student Role

• Non Violent
• Observe for safety Q60 minutes
• Monitor/Assess Every 2 Hours

• Monitor / Assess for
• Observe patient/device for correct application
  doing no harm
• Remove device and provide ROM
• Provide for personal care needs toileting,
  food, fluids, pain medication
• Take vital signs as ordered- Promptly report any
  changes or concerns to RN

• Self Violent, Destructive
• Observe for safety the patient Q 15 minutes
• Monitor/Assess Every 1 Hour

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RESTRAINT Devices / Safe Application

• General Guidelines
• Proper body alignment
• Call button can be used
• Patients head is free to rotate when in the
  supine position. When possible, head of bed
  slightly elevated to reduce risk of aspiration.
• Secure straps to bed or chair frame out of the
  patients reach using quick-release ties. DO NOT
  secure to mattress or side rail
• Side Rails
• Three side rails up equals safety
• Four side rails up equals restraint except for
  situations such as seizure precautions, age
  appropriate, pre/post anesthetic/sedative meds,
  vest restraint usage.
• Note gap in side rails must be covered when used
  with vest.

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RESTRAINT Devices / Safe Application

• Wrist Restraints
• Apply Correctly
  Allow one finger width
  between skin and device to ensure adequate
  circulation
• Remember to remove restraint and provide ROM
  every 2 hours.
• Monitor Use soft tissue not too tight cutting of
  blood flow, causing limb swelling or skin
  abrasions.
• Vest Restraints
• Ensure right size and fit
  Must fit at the waist and
  enable one flat hand to easily go under waist
  band.
• Apply correctly
  Opening in the back DO NOT
  criss-cross straps directly behind patient side
  rails up with gap pads
• Monitor Use device not choking patient or
  impairing breathing

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Abuse, Assault and Neglect Reporting

• Section 3

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Abuse, Assault, Neglect Reporting

• Who has Duty to Report?
• All physicians and health care providers
• What Must be Reported
• Abuse of Patients Received from Licensed Health
  Facilities
• Abuse of Elders and Dependant Adults
• Child Abuse
• Sexual Assault
• Adult Patient Abuse or Assault (includes spousal
  and domestic abuse)

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Abuse, Assault, Neglect Reporting

• How to Identify Possible Victims
• Consider the possibility when

• THE PATIENT
• History is incompatible with injuries.
• Has unusual injuries and/or unexplained bruises,
  lacerations, fractures or multiple injuries in
  various stages of healing.
• Presents with malnutrition or dehydration (not
  illness related), failure to thrive and/or poor
  physical hygiene.
• Has repeated ER visits, hospitalizations or a
  history of prior physical abuse.
• Delayed in seeking medical care.

• THE PARENT / SPOUSE / CAREPROVIDER
• Refuses to leave the patients presence despite
  the patients wishes.
• Offers conflicting, unconvincing or no
  explanation for patients injury.
• Delayed in getting medical care for the patient.

Action to Take Notify the primary RN immediately
of your suspicions.