Health Occupation Student Orientation Module 4: Provision of Care - PowerPoint PPT Presentation


Title: Health Occupation Student Orientation Module 4: Provision of Care


1
Health Occupation Student Orientation Module 4
Provision of Care
2
PATIENT SAFETY Goals
  • Section 1

3
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.

4
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

5
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

6
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.

7
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.
8
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.
9
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

10
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
11
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)

12
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
13
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

14
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
15
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

16
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.

17
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

18
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

19
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.

20
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.
21
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

22
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.

23
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

24
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

25
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,

26
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

27
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
28
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.

29
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!

30
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.)

31
RESTRAINTS
  • Section 2

32
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.)

33
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

34
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

35
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.

36
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

37
Abuse, Assault and Neglect Reporting
  • Section 3

38
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)

39
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.
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Health Occupation Student Orientation Module 4: Provision of Care

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Title: Health Occupation Student Orientation Module 4: Provision of Care


1
Health Occupation Student Orientation Module 4
Provision of Care
2
PATIENT SAFETY Goals
  • Section 1

3
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.

4
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

5
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

6
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.

7
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.
8
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.
9
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

10
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
11
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)

12
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
13
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

14
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
15
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

16
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.

17
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

18
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

19
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.

20
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.
21
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

22
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.

23
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

24
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

25
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,

26
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

27
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
28
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.

29
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!

30
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.)

31
RESTRAINTS
  • Section 2

32
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.)

33
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

34
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

35
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.

36
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

37
Abuse, Assault and Neglect Reporting
  • Section 3

38
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)

39
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.
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