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Title: NQF 34 Patient Safety Practices for Hospitals 2011 Part 1 of 2


1
NQF 34 Patient Safety Practices for Hospitals
2011Part 1 of 2
2
Speaker
  • Sue Dill Calloway RN, Esq. CPHRM
  • AD, BA, BSN, MSN, JD
  • Medical Legal consultant
  • 5447 Fawnbrook Lane
  • Dublin, Ohio 43017
  • sdill1_at_columbus.rr.com
  • 614 791-1468

2
2
3
NQF 34 SAFE PRACTICES
  • Released in 2003, updated 2006, 2009 and April
    2010
  • These should be followed in all healthcare
    facilities including
  • All clinical care settings to reduce risk of harm
    to patients especially hospitals
  • A roadmap to preventing harm
  • Have you done a gap analysis to see where your
    facility is at?
  • States 10 years after IOM report, To Err Is
    Human, uniformly reliably safety in healthcare
    has not been achieved
  • Several resources dovetail this publication

4
Patient Safety Primer
  • AHRQ has a patient safety primer that is designed
    to help users to understand key concepts in
    patient safety
  • It has a section on handoffs and sign-outs,
    healthcare associated infections, and adverse
    event after discharge
  • Never events, CPOE, medication reconciliation,
    disclosure, root cause analysis and rapid
    response systems
  • http//psnet.ahrq.gov/primerHome.aspx

5
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6
Patient Safety Handbook for Nurses
  • AHRQ has a free evidenced based handbook for
    nurses
  • Dove tails NQF 34 Safe Practices well
  • 1,400 pages and 51 separate chapters
  • Can print off, order the 3 volume set, or a CD
  • Includes chapters on many great topics such as
    defining patient safety, staffing, medications
    errors, patient centered care, falls, patient
    safety opportunities, handoffs, disclosure,
    communication, HAI, wrong site surgery, etc.,
  • At http//www.ahrq.gov/qual/nurseshdbk/

7
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8
Formats for Collecting Patient Safety Information
  • AHRQ and Dept of HHS have published common
    formats for collecting and reporting patient
    safety information, working with NQF,
  • Formats authorized by Patient Safety and Quality
    Improvement Act of 2005 (PSO),
  • Resource contains common definitions,
  • Includes reporting format for facilities to
    collect and track patient safety information in
    same manner,
  • available at http//www.pso.ahrq.gov

9
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10
2010 Updated Forward NQF 34 Safe Practices
  • This includes failure of an effective reporting
    system
  • Includes failure to learn from errors within a
    blame-free culture
  • Updated with current evidenced based
  • Systematic and universal implementation of these
    practices can lead to appreciable and sustainable
    improvements for healthcare safety
  • Manual includes latest safety evidence,
    implementation strategies, and guidance

11
Did You Know?
  • Preventable medical errors are actually on the
    rise by 1 per year
  • There are about 1.7 million HAIs and 99,000
    deaths a year
  • There are at least 1.5 million preventable drug
    events each year due to drug mix ups and
    unintentional over doses
  • 18 types of medical errors account for 2.4
    million extra hospital days and 9.3 billion in
    excess care
  • SourceSorra J, Famolaro T, et al. Hospital
    Survey on Patient Safety Culture 2008 Comparative
    Database Report. AHRQ Publication No. 08-0039.
    Rockville, MD Agency for Healthcare Research and
    Quality, 2008

12
Did You Know?
  • One in five patients discharged from the hospital
    end up sicker within 30 days and half are
    medication related
  • One of 10 inpatients suffers as a result of a
    mistake with medications which causes significant
    injury or death
  • Preventable medical errors cost the US 17 to 29
    billion dollars a year
  • Source Safe Practices for Better Healthcare Why
    Implement Practices to Improve Safety at
    http//www.qualityforum.org/News_And_Resources/Pre
    ss_Kits/Safe_Practices_for_Better_Healthcare.aspx

13
2010 Safe Practices
  • 34 Safe Practices for Better Healthcare
  • Organized into 7 functional categories
  • Leaders and boards are called upon to proactively
    review the safety of their organization and to
    take action to improve safety
  • Detailed bib list in book at end
  • Evidenced based and excellent resources
  • Also has list of 28 never events or serious
    reportable errors that many states require to be
    reported

14
NQF Other Publications
  • NQF also has a document on assessment and
    prevention of healthcare-associated infections
    (HAI),
  • Endorsed a set of Patient Safety Indicators
    developed by AHRQ (Agency for Healthcare Research
    and Quality,
  • www.ahrq.gov
  • Additional safety related work include
  • Prevention of venous thromboembolism (DVT)
  • Pressure ulcer prevention, perioperative care
  • Safety and medication management measures

15
AHRQ Patient Safety Indicators
www.qualityindicators.ahrq.gov/psi_overview.htm
16
How to Order the Book
  • Can be ordered at National Quality Forum at
    www.qualityforum.org or www.qualityforum.org/Publi
    cations/2010/04/Safe_Practices_for_Better_Healthca
    re__2010_Update.aspx
  • No cost for members
  • Non-member copy is 29.99 to download off website
  • Print copy is 89.99
  • Safe Practice for Better Healthcare-2010 Update
    A Consensus Report
  • Call 202 783-1300

17
2010 Resources
  • List of Safe Practices to show 2010 changes and
    new resources (48 pages)
  • http//qualityforum.org/News_And_Resources/Press_K
    its/Safe_Practices_for_Better_Healthcare.aspx
  • Free 11 page summary report
  • Press release for 2010 report
  • Free webinars at Texas Medial Institute of
    Technology (TMIT) at www.safetyleaders.org/home.js
    p
  • Also watch the Dennis Quade Patient Safety Video
    called Chasing Zero

18
Patient Safety Video
http//www.safetyleaders.org/pages/chasingZeroDocu
mentary.jsp
19
Resources on Safe Practices
  • NQF, publication unit, 601 Thirteenth Street, NW,
    Suite 500 North, Washington, DC, 2005
  • www.qualityforum.org
  • TMIT has a website at safetyleaders.org
  • Does free monthly programs on these at
    http//www.tmit1.org/pages/workshopsWebinars.jsp
  • Can listen to past presentations

20
TMIT Monthly Webinars
http//www.safetyleaders.org/pages/workshopsWebina
rs.jsp?step2
21
34 Practices Divided into 7 Chapters
  1. Creating and sustaining a culture of safety
  2. Informed consent, life sustaining treatment, care
    of caregiver, and disclosure
  3. Matching healthcare needs with service delivery
    capability
  4. Facilitating information management and clear
    communication
  5. Medication management
  6. Prevention of healthcare-associated infections
  7. Condition and site specific practices,

22
2010 NQF Report
23
2010 NQF Report
Culture
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems
  • Culture Measurement, Feedback and Interventions
  • Teamwork Training and Team Interventions
  • Identification and Mitigation of Risks and Hazards

ID Mitigation Risk Hazards
Team Training Team Interv.
Culture Meas., F.B., Interv.
Structures Systems
  • CHAPTER 1 Background
  • Summary, and Set of Safe Practices

Consent Disclosure

Consent Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent
  • Life-Sustaining Treatment
  • Disclosure

Informed Consent
Life-Sustaining Treatment
Disclosure
Workforce
CHAPTERS 2-8 Practices By Subject
  • CHAPTER 4 Workforce
  • Nursing Workforce
  • Direct Caregivers
  • ICU Care

Nursing Workforce
ICU Care
Direct Caregivers
  • CHAPTER 5 Information Management Continuity of
    Care
  • Critical Care Information
  • Order Read-back
  • Labeling Studies
  • Discharge Systems
  • Safe Adoption of Integrated Clinical Systems
    including CPOE
  • Abbreviations

Information Management Continuity of Care
Order Read-back
Critical Care Info.
CPOE
Abbreviations
Discharge System
Labeling Studies
Medication Management
  • CHAPTER 6 Medication Management
  • Medication Reconciliation
  • Pharmacist Role
  • Standardized Medication Labeling Packaging
  • High-Alert Medications
  • Unit-Dose Medications

Med. Recon.
Pharmacist Central Role
Std. Med. Labeling Pkg.
High-Alert Meds.
Unit-Dose Medications
  • CHAPTER 7 Hospital-Acquired Infections
  • Prevention of Aspiration and Ventilator-Associated
    Pneumonia
  • Central Venous Catheter-Related Blood Stream
    Infection Prevention
  • Surgical Site Infection Prevention
  • Hand Hygiene
  • Influenza Prevention

Healthcare-Associated Infections
Asp. VAP Prevention
Central V. Cath. BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention
  • CHAPTER 8
  • Evidence-Based Referrals
  • Wrong-Site, Wrong Procedure, Wrong Person Surgery
    Prevention
  • Perioperative Myocardial Infarct/Ischemia
    Prevention
  • Pressure Ulcer Prevention
  • DVT/VTE Prevention
  • Anticoagulation Therapy
  • Contrast Media-Induced Renal Failure Prevention


Condition- Site-Specific Practices
DVT/VTE Prevention
Anticoag. Therapy
Evidence- Based Ref.
Wrong-site Sx Prevention
Periop. MI Prevention
Press. Ulcer Prevention
Contrast Media Use
24
Culture
2010 NQF Report
Culture SP 1
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems
  • Culture Measurement, Feedback and Interventions
  • Teamwork Training and Team Interventions
  • Identification and Mitigation of Risks and Hazards
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems (Safe Practice 1)
  • Culture Measurement, Feedback and
    Interventions(Safe Practice 2)
  • Teamwork Training and Team Interventions (Safe
    Practice 3)
  • Identification and Mitigation of Risks and
    Hazards (Safe Practice 4)

ID Mitigation Risk Hazards
Team Training Team Interv.
Culture Meas, F.B, Interv.
Structures Systems
  • CHAPTER 1 Background
  • Summary, and Set of Safe Practices

Consent Disclosure

Consent Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent
  • Life Sustaining Treatment
  • Disclosure

Informed Consent
Life Sustaining Treatment
Disclosure
Work Force
CHAPTERS 2-8 Practices By Subject
  • CHAPTER 4 Workforce
  • Nursing Workforce
  • Direct Caregivers
  • ICU Care

Nursing Workforce
ICU Care
Direct Caregivers
  • CHAPTER 5 Information Management Continuity of
    Care
  • Critical Care Information
  • Order Read-back
  • Labeling Studies
  • Discharge Systems
  • Safe Adoption of Integrated Clinical Systems
    including CPOE
  • Abbreviations

Information Management Continuity of Care
Order Read-back
Critical Care Info.
CPOE
Abbreviations
Discharge System
Labeling Studies
Medication Management
  • CHAPTER 6 Medication Management
  • Medication Reconciliation
  • Pharmacist Role
  • Standardized Medication Labeling Packaging
  • High-Alert Medications
  • Unit-Dose Medications

Med. Recon.
Pharmacist Central Role
Std. Med. Labeling Pkg.
High-Alert Meds.
Unit-Dose Medications
  • CHAPTER 7 Hospital-Acquired Infections
  • Prevention of Aspiration and Ventilator-Associated
    Pneumonia
  • Central Venous Catheter-Related Blood Stream
    Infection Prevention
  • Surgical Site Infection Prevention
  • Hand Hygiene
  • Influenza Prevention

Hospital-Associated Infections
Asp. VAP Prevention
Central V. Cath BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention
  • CHAPTER 8
  • Evidence-Based Referrals
  • Wrong-Site, Wrong Procedure, Wrong Person Surgery
    Prevention
  • Perioperative Myocardial Infarct/Ischemia
    Prevention
  • Pressure Ulcer Prevention
  • DVT/VTE Prevention
  • Anticoagulation Therapy
  • Contrast Media-Induced Renal Failure Prevention


Condition- Site-Specific Practices
DVT/VTE Prevention
Anticoag. Therapy
Evidence- Based Ref.
Wrong-site Sx Prevention
Periop. MI Prevention
Press. Ulcer Prevention
Contrast Media Use
25
1. Leadership Structures and Systems
  • Leadership structures and systems must be
    established to ensure that there is
    organization-wide awareness of patient safety
    performance gaps,
  • Direct accountability of leaders for those gaps,
  • Adequate investment in performance improvement
    abilities,
  • Actions must be taken to ensure safe care of
    every patient served.

26
1. Leadership Structures and Systems
  • Do you have a patient safety program?
  • Is there education on patient safety and patient
    safety plan?
  • Just culture where frontline staff are
    comfortable disclosing errors but still maintains
    accountability?
  • Is there a patient safety officer?
  • Who coordinates patient safety education?
  • With direct and regular communication with board
    and senior leaders?
  • Senior leaders and department directors are
    accountable to close performance gaps

27
1. Leadership Structures and Systems
  • Is there an interdisciplinary patient safety
    committee?
  • Do leaders support the committee?
  • Board and leaders help set patient safety goals
  • Oversee RCA and feedback to frontline workers
  • Provides training in teamwork techniques
  • Direct organization-wide leadership
    accountability
  • Board briefed in results of culture survey and
    activities to identify and mitigate risks
  • Every board meeting should include patient safety
    issues

28
1. Leadership Structures and Systems
  • Direct patient input on formal committees on
    safety and not just patient satisfaction surveys
  • Board and senior leadership should regularly
    assess budgets for patient safety, people systems
    (staffing), PI, and technology that impact safety
  • Board members should be trained in team work
    (discussed later) and patient safety
  • Board should be competent in patient safety and
    do an annual assessment and ensure new board
    members well versed in patient safety

29
http//teamstepps.ahrq.gov/index.htm
30
1. Leadership Structures and Systems
  • Board and senior LD and CEO need to establish
    systems to ensure medical leaders have input into
    safety programs
  • CEO and senior leadership should design certain
    amount of time for patient safety activities
  • Teamwork training
  • Take actions to identify and mitigate risks and
    hazards (discussed in detail later)
  • Regular patient safety related session at
    meetings
  • Weekly walk-rounds

31
Patient Safety Walk Abouts
  • Also called leadership walk rounds or executive
    walk rounds
  • AHA has easy to use manual developed in
    conjunction with 3 year pilot program in 10
    hospitals
  • 200 hospitals used thru IHI collaboration
  • Research shows positive effect on safety culture
    attitudes of nurses and improves safety culture

32
AHA Opening Statement
  • We are moving as an organization to open
    communication and a blame-free environment
    because we believe that by doing so we can make
    your work environment safer for you and your
    patients.  The discussion we are interested in
    having with you is confidential and purely for
    patient safety and improvement. 
  • We are interested in focusing on the systems you
    work in each day rather than on blaming specific
    individuals. The questions we might ask you will
    tend to be general ones, and you might consider
    how these questions might apply in your work
    areas in regards medication errors, communication
    or teamwork problems, distractions,
    inefficiencies, problems with protocols etc.

33
AHA Opening Statement
  • We are happy to discuss any issues of concern to
    you. Our goal is to take what we learn in these
    conversations and use them to improve your work
    environment and the overall delivery of care.

34
Questions Asked in Walk Rounds
  • Have there been any near misses that almost
    caused patient harm today?
  • Have we harmed any patients recently?
  • What aspects of the environment are likely to
    lead to harm?
  • Is there anything we could do to prevent the next
    adverse event?
  • http//www.wsha.org/files/82/WalkRounds1.pdf and
    http//www.hret.org/hret/programs/protemp.html

35
Questions Asked in Walk Rounds
  • Can you think of any events in the past days
    which have resulted in prolonged hospitalization
    for a patient?
  • Can you think of a way in which the system or
    your environment fails you on a continual basis?
  • Would specific interventions from leadership
    could make your work safer?
  • What would make this executive walkabout more
    effective?

36
Patient Safety Walk Rounds IHI ihi.org
37
Patient Safety Walk Rounds AHA
38
2. Culture Measurement, Feedback, Intervention
  • Hospitals must measure their culture,
  • Provide feedback to the leadership and staff,
  • Hospitals must undertake interventions that will
    reduce patient safety risk

39
Definition of Patient Safety
  • Definition of Patient Safety by NQF
  • Freedom from injury or illness resulting from the
    processes of care,
  • Patient safety event is an occurrence or
    potential occurrence, that is directly linked to
    the delivery of healthcare that results, or could
    result, in injury, death, or illness,

40
AHRQ Survey Tool
  • Need to measure culture and provide feedback at
    least on yearly basis
  • Patient Safety Culture Survey website
  • at www.ahrq.gov/qual/patientsafetyculture/
  • Has a hospital survey on patient safety culture
  • TJC LD.03.01.01 requirement
  • EP 1 Leaders regularly evaluate the culture of
    safety and quality using valid and reliable tools
  • Many similar TJC leadership standards

41
AHRQ Survey Tool
  • AHRQ survey tool you can compare your data to
    other hospitals
  • Hospital survey toolkit and comparative database
    report available, survey users guide, survey
    items and domains, feedback templates, assistance
    briefings, etc.,
  • AHRQ has tool for hospitals, nursing homes and
    physician offices
  • Domains include teamwork, communication, PI,
    leadership and openness to reporting
  • Disseminate results

42
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43
Hospital Survey AHRQ
44
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45
Patient Safety Culture Questions
  • Communication and frequency of events reported
    section
  • Staff will speak up if they see something that
    may negatively affect patient care
  • Staff feel free to question the decisions of
    those with more authority
  • Do staff feel like their mistakes are held
    against them?
  • Do staff worry that mistakes they make are kept
    in their personnel file?

46
Patient Safety Culture Questions
  • Staff are afraid to ask questions when something
    does not seem right
  • Is mistake caught still reported (TJC and CMS
    require reporting of near misses)
  • Problems often occur in the exchange of
    information
  • Staff feel there are patient safety problems on
    the unit?
  • See safety toolkits for leaders at
    www.mnhospitals.org/index/toolkits

47
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48
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49
3. Teamwork Training Skill Building
  • Healthcare organizations must establish a
    proactive, systematic, organization-wide approach
  • to developing team-based care through teamwork
    training,
  • skill building,
  • and team-led performance improvement
    interventions that reduce preventable harm to
    patients.

50
3. Team Work
  • Every hospital should have team work and
    communication training (time out before surgery,
    huddles, SBAR, hand-offs) and at all levels
  • Start with staff in areas with high risk (ICU,
    ED, Perinatal)
  • Should include hand-offs, communication failures,
    team failures that lead to patient harm
  • Should include high reliability principles,
    human factors, and interpersonal team dynamics
  • Good place to get resources on these topics is
    AHRQ PSNet at http//www.psnet.ahrq.gov/

51
3. Team Work
  • Should include effective skill building such as
    stop the line method
  • Should document team training
  • Identify every year number of teamwork-centered
    intervention projects such as specific team PI
    projects (ED, LD, OR, ambulatory, ICU), rapid
    response assessment (RRT),
  • Crew Resource Management (CRM) and AHRQ
    TeamSTEPPS are two examples
  • CRM used in airline safety and originated from
    NASA to prevent human error

52
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53
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54
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55
http//teamstepps.ahrq.gov/index.htm
56
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57
4. Identification Mitigation of Risks Hazards
  • Healthcare organizations must systematically
    identify and mitigate patient safety risks and
    hazards
  • with an integrated approach
  • in order to continuously drive down preventable
    patient harm

58
4. Identification Mitigation of Risks Hazards
  • Need to identify risks and hazards on an ongoing
    basis
  • Need to include information gained from multiple
    sources
  • Culture should focus on system and not
    individuals (system analysis theory)
  • Including blame free reporting to create a just
    culture

59
Chasing Zero Winning the War on Healthcare Harm
http//link.brightcove.com/services/player/bcpid79
301804001
60
Videos You Should Watch Share Rounds
61
The Power of a Story Jossie King
62
4. Identification Mitigation of Risks Hazards
  • Annual report should be done on progress on
    evaluation of activities and tools used
  • Serious reportable events (NQF lists 28)
  • Sentinel event reporting (TJC has a list of
    reviewable sentinel events)
  • Adverse event reporting, RCA done
  • Closed claims analysis, skill mix
  • Patient safety indicators (AHRQ has)
  • Trigger tools (IHI has 9)

63
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64
4. AHRQ Patient Safety Indicators
  • These are a tool to help leaders identify
    potential adverse events during hospitalization
  • Identify complication following surgeries,
    procedures, and childbirth
  • PSIs is a software tool from AHRQ to help
    identify AE that need further study
  • Developed by Stanford University and University
    of California under contract with AHRQ

65
AHRQ Patient Safety Indicators
www.qualityindicators.ahrq.gov/psi_overview.htm
66
IHI Trigger Tools
www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral
/Tools/IntrotoTriggerToolsforIdentifyingAEs.htm
67
4. FMEA or PRA
  • Hospitals should do one proactive risk assessment
    per year
  • FMEA or failure mode and effect analysis
  • PRA or probablistic risk assessment (looks at
    risk by severity or likelihood of occurrence and
    what could go wrong and uses fault tree analysis)
  • TJC in LD.04.04.05 also requires
  • EP6. The hospital defines responses to various
    types of potential AE. There needs to be a system
    approach for blame free reporting of a system or
    process failure. This also included the results
    of the proactive risk assessment (FMEA),

68
Sample FMEA Anticoagulant ISMP
69
4. Organization Wide Risk Management
  • Look at risks and hazards across the organization
    to identify patterns, system failures and
    contributing patterns
  • Risk management and claims management
  • Complaints and customer service participation
  • Culture measurement and intervention
  • Disclosure support system
  • Anticipated risk for surge in capacity as for flu
    pandemic or disaster

70
4. PI Program
  • PI program to close patient safety gaps
  • Need targeted PI projects aimed at patient safety
  • Need products and technologies for quality and
    patient safety (bar coding, smart pumps,
    automated dispensing unit)
  • Use dashboards or scorecard to document progress
    of all patient safety programs

71
4. Risk Assessment and Mitigation
  • Document following high risk areas and actions
    takes to close patient safety gaps
  • Falls and effectiveness of fall reduction program
  • Malnutrition
  • Pneumatic tourniquets and evaluate for risk of
    ischemia and or thrombotic complications
  • Aspiration assessment upon admission
  • Workforce fatigue (Pa Patient Safety Authority
    has toolkit at http//patientsafetyauthority.org/E
    ducationalTools/PatientSafetyTools/aspiration/Page
    s/home.aspx

72
PA Patient Safety Authority
73
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74
Culture
2010 NQF Report
Culture SP 1
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems
  • Culture Measurement, Feedback and Interventions
  • Teamwork Training and Team Interventions
  • Identification and Mitigation of Risks and Hazards

ID Mitigation Risk Hazards
Team Training Team Interv.
Culture Meas., F.B., Interv.
Structures Systems
  • CHAPTER 1 Background
  • Summary, and Set of Safe Practices

Consent Disclosure

Consent Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent
  • Life-Sustaining Treatment
  • Disclosure

Informed Consent
Life Sustaining Treatment
Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent (Safe Practice 5)
  • Life-Sustaining Treatment (End of Life, Safe
    Practice 6)
  • Disclosure (Safe Practice 7)
  • Care of the Caregiver (Safe Practice 8)

Work Force
CHAPTERS 2-8 Practices By Subject
  • CHAPTER 4 Workforce
  • Nursing Workforce
  • Direct Caregivers
  • ICU Care

Nursing Workforce
ICU Care
Direct Caregivers
  • CHAPTER 5 Information Management Continuity of
    Care
  • Critical Care Information
  • Order Read-back
  • Labeling Studies
  • Discharge Systems
  • Safe Adoption of Integrated Clinical Systems
    including CPOE
  • Abbreviations

Information Management Continuity of Care
Order Read-back
Critical Care Info.
CPOE
Abbreviations
Discharge System
Labeling Studies
Medication Management
  • CHAPTER 6 Medication Management
  • Medication Reconciliation
  • Pharmacist Role
  • Standardized Medication Labeling Packaging
  • High-Alert Medications
  • Unit-Dose Medications

Med. Recon.
Pharmacist Central Role
Std. Med. Labeling Pkg.
High-Alert Meds
Unit-Dose Medications
  • CHAPTER 7 Hospital-Acquired Infections
  • Prevention of Aspiration and Ventilator-Associated
    Pneumonia
  • Central Venous Catheter-Related Blood Stream
    Infection Prevention
  • Surgical Site Infection Prevention
  • Hand Hygiene
  • Influenza Prevention

Hospital-Associated Infections
Asp. VAP Prevention
Central V. Cath BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention
  • CHAPTER 8
  • Evidence-Based Referrals
  • Wrong-Site, Wrong Procedure, Wrong Person Surgery
    Prevention
  • Perioperative Myocardial Infarct/Ischemia
    Prevention
  • Pressure Ulcer Prevention
  • DVT/VTE Prevention
  • Anticoagulation Therapy
  • Contrast Media-Induced Renal Failure Prevention


Condition- Site-Specific Practices
DVT/VTE Prevention
Anticoag. Therapy
Evidence- Based Ref.
Wrong-site Sx Prevention
Periop. MI Prevention
Press. Ulcer Prevention
Contrast Media Use
75
NQF Safe Practices Informed Consent
  • Ask each patient or legal surrogate to "teach
    back" key information about proposed treatments
    or procedures for which he or she is asked to
    provide informed consent

76
5. Informed Consent
  • Patient should be able to explain in everyday
    words their diagnosis or health problem for which
    they need care
  • CMS Hospital CoP Patient Right for patient to
    know their diagnosis and prognosis
  • Patient should know the name of the treatment or
    procedure
  • This includes risks, benefits, and alternatives
  • CMS has 3 sections in hospital CoP on informed
    consent including 6 mandatory elements
  • Consent is a process and not a form

77
5. Informed Consent
  • Remember to include your state law on consent
  • TJC RI.01.03.01 has consent standard with 13 EPs
  • TJC 2011 patient-provider communication standards
  • Informed consent documents written at 5th grade
    level
  • Remember low health literacy issue
  • Interpreter used if does not speak English
  • Please tell me in your own words what you surgery
    you are having done
  • Minnesota project to get consent to be
    understandable

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www.mnpatientsafety.org/index.php?optioncom_conte
nttaskviewid85Itemid69
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Ask Me 3 Website
81
Informed Consent Summary
  • Know your policy and procedure
  • Document consent in medical record
  • Make sure on chart before they go to surgery
  • Know state law, TJC standards, CMS hospital CoPs,
    AOA HCAP standard, DNV NIAHO (National Integrated
    Accreditation for Healthcare Organizations) or
    whatever standard applies to your facility
  • Policy states when surrogate decision makes may
    give informed consent such as guardian or DPOA

82
NQF Safe Practices Life Sustaining Treatment
  • Ensure that written documentation of the
    patient's preferences for life- sustaining
    treatments is prominently displayed in his or her
    chart,

83
6. Life Sustaining Treatment
  • Have a process in place to determine what
    preference patient has and document
  • Prominently display in chart
  • Know what advance directives the patient has
  • Document their wishes
  • DNR, DPOA, Organ donor, Living will, Mental
    health declaration
  • Have sticker on front of chart
  • TJC standard to have way to communicate to other
    departments (The Joint Commission, no longer
    JCAHO)

84
6. Life Sustaining Treatment
  • Document on admission if patient wants to make
    any changes (TJC standard also),
  • Give written copy of patient rights (CMS
    requirement)
  • Facility helps patient formulate advance
    directives
  • PP to the extent hospital will honor them
  • Have copies on the chart of ADs

85
6. Life Sustaining Treatment
  • Refer patient or assist in formulating advance
    directives (TJC and CMS)
  • Adults are given information on their right to
    refuse care (TJC and CMS requirement)
  • Be aware of how spiritual beliefs affect their
    view of end of life care
  • Physicians and caregivers need education on how
    compassion fatigue and self awareness to minimize
    burnout

86
NQF Safe Practices 7 Disclosure
  • Following serious, unanticipated outcomes, the
    patient and, as appropriate, family should
    receive communication about the event,
  • Called disclosure of unanticipated outcomes

87
7. Disclosure of Unanticipated Outcomes (UO)
  • At a minimum must include sentinel events (TJC),
    serious reportable events (NQF), and any UO
    involving harm such as increased LOS (length of
    stay), additional care such as a test or
    procedure, loss of limb or function lasting 7
    days or longer
  • Need PP
  • Need a formal process for disclosing
  • Provide all LIPs with detailed description of
    program including full disclosure
  • Document in the medical record (also TJC standard
    RC.02.01.05 EP1)

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7. Disclosure
  • Leadership needs to make sure information is used
    for performance improvement
  • Adherence should be part of credentialing
  • Includes what information should be communicated
    to patient such as the facts, empathic
    communication, commitment to investigate and
    provide to patient safety leaders, results of
    investigations, timeliness, an apology
  • Emotional support for patients by trained
    caregivers
  • Emotional support for caregivers

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7. Disclosure
  • Consider a disclosure coach
  • Consider providing information to a PSO
  • Process in place for early remediation and
    waiving of billing and for subsequent treatment
    if system or human failure
  • TJC standard , NPSF statement, and AMA Code of
    Ethics on this
  • RI.01.02.01 EP21 Patient or surrogate decision
    maker is informed about outcomes of care and
    treatment in order to participate in current and
    future healthcare decisions

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TJC Disclosure Standard
  • EP22 LIP responsible for managing patients
    care, or their designee, informs the patient
    about the unanticipated outcomes (UO) related to
    SE when patient is not aware of the occurrence or
    where further discussion is needed

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National Patient Safety Foundation
  • Talking to patients about Health Care Injury.
  • Available at http//www.npsf.org
  • When a health care injury occurs, the patient and
    the family or representative is entitled to a
    prompt explanation of how the injury occurred and
    its short and long-term effects. When an error
    contributed to the injury, the patient and the
    family or representative should receive a
    truthful and compassionate explanation about the
    error and the remedies available to the patient.
  • They should be informed that the factors
    involved in the injury will be investigated so
    that steps can be taken to reduce the likelihood
    of similar injury to other patients.

92
ASHRM 4 Documents on UO
  • 20 page document titled Perspective on
    disclosure of unanticipated outcome information
  • Provides examples of UO Policy and procedures
  • Has additional 3 documents, Disclosure What
    works now and what can work even better,
  • Disclosure Creating an effective patient
    communication policy, and.
  • Disclosure the next step in better
    communications with patients,
  • At http//www.ashrm.org/ashrm/resources/monograph.
    html

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APhysician need to discloseBPatient need to
hear
Who Needs What and When?
A
B
Need
Time
94
AMA Code of Medical Ethics Section 8.12
  • States physician has ethical duty to deal
    honestly and openly with patient at all times
  • Patients have right to know their past and
    present medical condition
  • and to be free of any mistaken beliefs
  • This includes all facts necessary to understand
    what has occurred-regardless of legal liability
    that might result

95
Unanticipated Outcomes
  • Often patients just want to know changes will be
    made so will not happen to someone else
  • They want to know change will be made
  • Some facilities offer upfront compensation
  • Many recent articles to show physicians are not
    doing this right
  • In reality this is much more complicated than it
    looks

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Sorry Works
  • Consider sorry works initiative
  • Adopted by a large number of hospitals throughout
    the country
  • To reduce lawsuits
  • Believe that apologies and upfront compensation
    for medical errors reduces lawsuits and liability
    costs
  • Need to have a successful disclosure program.
  • Go to www.sorryworks.net
  • See also Canadian Disclosure Guidelines at
    www.patientsafetyinstitute.ca

97
Sorry Works
  • Supported by studies done at Lexington VA
    hospitals/all VA hospitals and
  • University of Michigan/Stanford University and
    Harvard Teaching Hospitals and many others
  • Stay in close contact with patient/family and
    return all phone calls promptly and pleasantly
  • Remember RCA
  • Apology for what happened and explained what
    happened and how you fixed it
  • Should always check with your malpractice carrier

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NQF Safe Practice 8 Care of the Caregiver
  • Following serious unintentional harm due to
    systems failures and/or errors
  • That resulted from human performance failures
  • The involved caregivers (clinical providers,
    staff, and administrators) should receive timely
    and systematic care to include
  • Treatment that is just, respect, compassion,
    supportive medical care, and the opportunity to
    fully participate in event investigation and risk
    identification and mitigation activities that
    will prevent future events

99
8. Care of the Caregiver
  • Caregivers includes all providers and staff
    involved in adverse events
  • An OB nurse works a double and stays at the
    hospital to get a few hours of sleep before she
    starts the day shift
  • A 16 year old comes in and she has the IV
    antibiotic and IV for the Epidural infusion in
    her hand
  • She administers the wrong one and the patient
    dies
  • She loses her license, her job, and is criminally
    charged

100
8. Care of the Caregiver
  • IV tubings look alike, no bar coding, fatigued
    healthcare worker, no double checks
  • Was this fair and just?
  • Lead to the development of this chapter
  • Harm can occur to caregivers
  • depression, anxiety, sleeping difficulties etc.
  • If not managed correctly harm can occur to the
    culture of the organization
  • Process to provide information to a PSO that
    protects confidential information

101
8. Care of the Caregiver
  • Need evidenced based process to assess behavior
    of those involved with an AE to identify if
    substance abuse, intentional harm, reckless
    disregard of clear PP (Just Culture Theory)
  • If system failure or predictable human
    performance factor then clear from direct
    personal blame within 24 hours
  • If contemplating a corrective action that could
    result in serious loss of livelihood the person
    should be notified and give opportunity to seek
    legal counsel before providing a formal statement

102
8. Care of the Caregiver
  • Designated leaders should be trained in the
    critical importance of forgiveness and process to
    have co-workers express understanding and
    compassion
  • Supportive care for the caregiver in serious
    unintentional harm and opportunity to receive
    professional help (Employee Assistance Programs)
  • Just in time coaching to leaders who are involved
    with this process with formal system to educate
    senior leaders, staff and caregiver

103
Culture
2010 NQF Report
Culture SP 1
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems
  • Culture Measurement, Feedback and Interventions
  • Teamwork Training and Team Interventions
  • Identification and Mitigation of Risks and Hazards

ID Mitigation Risk Hazards
Team Training Team Interv.
Culture Meas, F.B, Interv.
Structures Systems
  • CHAPTER 1 Background
  • Summary, and Set of Safe Practices

Consent Disclosure

Consent Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent
  • Life Sustaining Treatment
  • Disclosure

Informed Consent
Life Sustaining Treatment
Disclosure
  • CHAPTER 4 Workforce
  • Nursing Workforce (Safe Practices 9)
  • Direct Caregivers (Safe Practices 10)
  • ICU Care (Safe Practices 11)

Work Force
CHAPTERS 2-8 Practices By Subject
  • CHAPTER 4 Workforce
  • Nursing Workforce
  • Direct Caregivers
  • ICU Care

Nursing Workforce
ICU Care
Direct Caregivers
  • CHAPTER 5 Information Management Continuity of
    Care
  • Critical Care Information
  • Order Read-back
  • Labeling Studies
  • Discharge Systems
  • Safe Adoption of Integrated Clinical Systems
    including CPOE
  • Abbreviations

Information Management Continuity of Care
Order Read-back
Critical Care Info.
CPOE
Abbreviations
Discharge System
Labeling Studies
Medication Management
  • CHAPTER 6 Medication Management
  • Medication Reconciliation
  • Pharmacist Role
  • Standardized Medication Labeling Packaging
  • High-Alert Medications
  • Unit Dose Medications

Med Recon.
Pharmacist Central Role
Std. Med Labeling Pkg
High Alert Meds
Unit Dose Medications
  • CHAPTER 7 Hospital-Acquired Infections
  • Prevention of Aspiration and Ventilator
    Associated Pneumonia,
  • Central Venous Catheter Related Blood Stream
    Infection Prevention
  • Surgical Site Infection Prevention
  • Hand Hygiene
  • Influenza Prevention

Hospital Associated Infections
Asp VAP Prevention
Central V. Cath BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention
  • CHAPTER 8
  • Evidence-Based Referrals
  • Wrong Site, Wrong Procedure, Wrong Person Surgery
    Prevention
  • Peri-operative Myocardial Infarct/Ischemia
    Prevention
  • Pressure Ulcer Prevention
  • DVT/VTE Prevention
  • Anticoagulation Therapy
  • Contrast Media-Induced Renal Failure Prevention


Condition Site Specific Practices
DVT/VTE Prevention
Anticoag Therapy
Evidence Based Ref.
Wrong site Sx Prevention
Peri-Op MI Prevention
Press. Ulcer Prevention
Contrast Media Use
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NQF Safe Practices 9
  • Implement critical components of a well designed
    nursing workforce,
  • That mutually reinforce patient safeguards,
    including the following
  • A nurse staffing plan with evidence that it is
    adequately resourced and actively managed and
    that its effectiveness is regularly evaluated
    with respect to patient safety.

105
NQF Safe Practices 9
  • Senior administrative nursing leaders, such as a
    Chief Nursing Officer, is part of the hospital
    senior management team (TJC standard)
  • Boards and senior administrative leaders that
    take accountability for reducing patient safety
    risks related to nurse staffing decisions and the
    provision of financial resources for nursing
    services
  • Provision of budgetary resources to support
    nursing staff in the ongoing acquisition and
    maintenance of professional knowledge and skills.

106
9. Nursing Workforce
  • PP, with input from nurses, on effective
    staffing that specify number, competency, and
    skill mix of nursing staff
  • Ensure board, senior and mid management are
    educated on impact of staffing on safety
  • Conduct risk assessments related to nurse
    staffing, work hours and temporary coverage
  • Use data to monitor staff level (sensitive
    nursing indicators such as more falls, medication
    errors, longer LOS, codes, GI bleeds, UTIs, etc.

107
Nursing Linked to Safety
  • Adequate staffing levels linked to safety
  • Limits number of hours worked to prevent fatigue
  • 38 more likely to make an error if work over 12
    hours
  • No mandatory overtime
  • There are three major studies
  • Redesigning the work force, See Keeping Patients
    Safe Transforming the Work Environment of Nurses
    2004, IOM at www.nap.edu/openbook/0309090679/html/
    23/html, see multiple studies pg 227-239,

108
Nursing Linked to Safety
  • March 2007, Nursing Staffing and Quality of
    Patient Care, AHRQ Pub No. 07-E005, Minnesota
    Evidenced Based Practice Center, at
    http//www.ahrq.gov/downloads/pub/evidence/pdf/nur
    sestaff/nursestaff.pdf
  • Patient Safety and Quality An Evidenced Based
    Handbook for Nurses, AHRQ Publication No.08-0043,
    2008, Chapter 25 Nurse Staffing and Patient Care
    Quality and Safety at http//www.ahrq.gov/qual/nur
    seshdbk/

109
9. Nursing Workforce
  • Ongoing assessment to make sure nurses are
    oriented and competent to provide safe care
  • Including float nurses, contract staff and agency
    nurses
  • Matching healthcare needs with service delivery
    capability to improve patient safety

110
Safe Practice 10 Direct Caregivers
  • Ensure that non-nursing direct care staffing
    levels are adequate,
  • That the staff are competent,
  • That they have had adequate orientation,
    training, and education to perform their assigned
    direct care duties

111
10 Direct Non-Nursing Caregivers
  • Establish a staffing plan that is adequately
    resourced and managed
  • Do risk assessment to identify patient safety
    risks related to non-nursing direct care workers
    including work hours and staffing
  • Ensure resources for PI program based on risk
    assessment
  • Have PP to meet staffing targets to include
    number, competency and skill mix

112
Safe Practice 11 ICU Care
  • All patients in general intensive care units
    (both adult and pediatric)
  • Should be managed by physicians who have specific
    training and certification in critical care
    medicine (critical care certified)

113
11 ICU Care
  • Dedicated critical care certified physicians
    should be present in the ICU during daytime hours
  • 8 hours a day and seven days a week
  • If unable to have 8 hours then round the clock
    eICU monitored by critical care physician
  • If critical care physician not present then
    physician shall provide telephone coverage
  • Must return 95 of ICU pages within 5 minutes

114
Critical Care Patients
  • Make sure the critically ill have appropriately
    skilled caregivers in the ICU
  • Studies show errors are common in the ICU
  • 20 of all ICU patients have serious adverse
    event
  • Higher mortality rate if you do not have a
    physician trained and certified in critical care
    medicine
  • See book on Critical Care Safety Essentials for
    ICU Patient Care and Technology by ECRI
  • 610 825-6000 or www.ecri.org,

115
Culture
2010 NQF Report
Culture SP 1
  • CHAPTER 2 Creating and Sustaining a Culture of
    Patient Safety
  • Leadership Structures Systems
  • Culture Measurement, Feedback and Interventions
  • Teamwork Training and Team Interventions
  • Identification and Mitigation of Risks and Hazards

ID Mitigation Risk Hazards
Team Training Team Interv.
Culture Meas., F.B., Interv.
Structures Systems
  • CHAPTER 1 Background
  • Summary, and Set of Safe Practices

Consent Disclosure

Consent Disclosure
  • CHAPTER 3 Informed Consent Disclosure
  • Informed Consent
  • Life-Sustaining Treatment
  • Disclosure

Informed Consent
Life-Sustaining Treatment
Disclosure
  • CHAPTER 5 Information Management Continuity of
    Care
  • Patient Care Information (Safe Practice 12)
  • Order Read-Back and Abbreviations (Safe Practice
    13)
  • Labeling and Diagnostic Studies (Safe Practice
    14)
  • Discharge Systems (Safe Practice 15)
  • CPOE (Safe Practice 16)

Workforce
CHAPTERS 2-8 Practices By Subject
  • CHAPTER 4 Workforce
  • Nursing Workforce
  • Direct Caregivers
  • ICU Care

Nursing Workforce
ICU Care
Direct Caregivers
  • CHAPTER 5 Information Management Continuity of
    Care
  • Critical Care Information
  • Order Read-back
  • Labeling Studies
  • Discharge Systems
  • Safe Adoption of Integrated Clinical Systems
    including CPOE
  • Abbreviations

Information Management Continuity of Care
Order Read-back
Critical Care Info.
CPOE
Abbreviations
Discharge System
Labeling Studies
Medication Management
  • CHAPTER 6 Medication Management
  • Medication Reconciliation
  • Pharmacist Role
  • Standardized Medication Labeling Packaging
  • High-Alert Medications
  • Unit Dose Medications

Med Recon.
Pharmacist Central Role
Std. Med Labeling Pkg
High Alert Meds
Unit Dose Medications
  • CHAPTER 7 Hospital-Acquired Infections
  • Prevention of Aspiration and Ventilator-Associated
    Pneumonia
  • Central Venous Catheter Related Blood Stream
    Infection Prevention
  • Surgical Site Infection Prevention
  • Hand Hygiene
  • Influenza Prevention

Hospital-Associated Infections
Asp. VAP Prevention
Central V. Cath BSI Prevention
Sx Site Inf. Prevention
Hand Hygiene
Influenza Prevention
  • CHAPTER 8
  • Evidence-Based Referrals
  • Wrong-Site, Wrong Procedure, Wrong Person Surgery
    Prevention
  • Perioperative Myocardial Infarct/Ischemia
    Prevention
  • Pressure Ulcer Prevention
  • DVT/VTE Prevention
  • Anticoagulation Therapy
  • Contrast Media-Induced Renal Failure Prevention


Condition- Site-Specific Practices
DVT/VTE Prevention
Anticoag. Therapy
Evidence- Based Ref.
Wrong-site Sx Prevention
Periop. MI Prevention
Press. Ulcer Prevention
Contrast Media Use
116
NQF Safe Practices 12
  • Ensure that care information is transmitted and
    documented in a timely and clearly understandable
    form to patients and patient's healthcare
    providers within and between care settings.
  • Recall that 70 of all errors are due to
    communication failures,

117
12 Patient Care Information
  • Identify communication gaps about critical test
    results and include in PI
  • Implement process that critical results are
    communicated quickly to the LIP
  • Values defined as critical by the lab must be
    reported in specified timeframes
  • Have process to report critical test results to
    alternative practitioner if patients LIP is not
    available
  • Ensure patients have access to their MR within 24
    hours of written request (not 30 days as in HIPAA)

118
TJC 2011 NPSG 2 Critical Results of Tests
  • NPSG.02.03.01 Report critical results of tests
    and diagnostic procedures on a timely basis
  • EP 1 Develop procedures for managing the critical
    results of tests and diagnostic procedures that
    address the following
  • Definition of critical test results and
    diagnostic procedures
  • By who and to whom critical results are reported
  • Acceptable length of time between availability of
    results and calling

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TJC Goal 2 Critical Test Results
  • EP 2 Implement the procedure for managing
    critical results of tests and diagnostic
    procedures
  • EP3 Evaluate the timeliness of reporting critical
    test results and diagnostic procedure results
  • Term critical tests has been removed and now
    talks about critical results
  • Critical results are tests and diagnostic
    procedures which fall significantly outside the
    normal range and could indicate a life
    threatening situation
  • Want to be sure patient is promptly treated so
    let doctor know blood sugar is 760

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NQF 13 Order Read Back Abbreviations
  • Incorporate within your organization a safe,
    effective communication strategy, structures, and
    systems to include the following
  • For verbal or telephone orders or for telephonic
    reporting of critical test results, verify the
    complete order or test result by having the
    person who is receiving the information record
    and read-back the complete order or test result
  • TJC PC.02.01.03 and CMS CoPs also require this

122
NQF 13 Order Read Back Abbreviations
  • Standardize a list of Do Not Use abbreviations,
    acronyms, symbols, and dose designations that
    cannot be used throughout the organization
  • TJC had 9 do not use abbreviations and moved in
    2010 from NPSG to IM.02.02.01 which continues in
    2011

123
TJC Information Management IM.02.02.01
  • EP3 The policy must be implemented regarding the
    terminology, definitions, abbreviations,
    acronyms, symbols, and dose designations
    permitted for use in the hospital
  • And the do not use abbreviations, acronyms,
    symbols, and doses

123
124
NQF 13 Order Read Back Abbreviations
  • Do not use verbal orders unless impossible for
    practitioner to write the order
  • CMS 407, 408, 454, 457 and TJC standard also
    PC.02.03.07 and RC.02.03.07
  • Need PP to minimize the use of verbal orders
  • Write it down or enter it into the computer and
    repeat it back
  • Receive confirmation back
  • Prohibit u, IU, qd, qod, trailing zero, absence
    of leading zero, MS, MSO4 or MgSO4

125
Dangerous Abbreviations
  • Institute for Safe Medication Practices (ISMP)
    has published a list of dangerous abbreviations
    relating to medication use
  • Post copies in nursing station and give copy to
    all physicians
  • Go to www.ismp.org or http//www.ismp.org/PDF/Erro
    rProne.pdf
  • Trailing zero is prohibited only for medication
    related notations-okay for lab such as K is 4.0
    or ET tube is 7.0

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Labeling of Diagnostic Studies Safe Practice 14
  • Implement standardized policies, processes, and
    systems
  • To ensure accurate labeling of radiographs,
    laboratory specimens, or other diagnostic
    studies,
  • So that the right study is labeled for the right
    patient at the right time

128
14. Labeling of Diagnostic Studies
  • Label lab specimen containers at time of use in
    the presence of the patient
  • Also a TJC requirement NPSG.01.01.01
  • Match the patient to the intended service or
    treatment using two identifiers
  • Can not be floor or room number
  • When taking blood or other specimens and for
    treatments
  • Label x-ray imaging studies with correct
    information while in the darkroom or close to the
    imaging device

129
TJC Goal 1Improve the accuracy of patient
identification. 
  • Recommendations Use at least two patient
    identifiers when providing care, treatment or
    services.
  • Use two identifiers in administering meds or
    hanging blood or blood products, when collecting
    blood samples or other specimens for clinical
    testing and (EP 2),
  • Reference to what to do before starting a blood
    transfusion under NPSG.01.03.01 EP1
  • Must label blood and other specimens in presence
    of patient (no batching or prelabeling the
    vials, EP 6),

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14. Labeling of Diagnostic Studies
  • Make right or left on images to prevent
    misinterpretation at the light box
  • Monitor and report errors and harm related to
    mislabeling
  • In surgery, debriefing can help prevent this
  • There are many studies to show the high number of
    specimens that are labeled incorrectly or have
    errors
  • Include as part of PI project

131
www.scoap.org
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Labeling of Specimens
  • 2007 study looked at 21,000 surgical specimens,
    91 errors,
  • Error rate was 4.3 per 1000 specimen,
  • Error rates higher for specimens associated with
    a biopsy procedure and in the outpatient setting,
  • Specimen mislabeling was one kind of error,
  • TJC addresses specimen labeling in the NPSGs,
  • Found surgical specimen identification errors are
    common and pose risk to patients,
  • Strategies to reduce this risk should be research
    priority,
  • Surgery, 2007, April, Makary MA,

135
Labeling of Specimens
  • Study found
  • 18 specimens not labeled,
  • 16 empty containers,
  • 16 incorrect laterality,
  • 14 incorrect tissue site,
  • 11 incorrect patient,
  • 9 no patient name,
  • 7 no tissue site,
  • Procedures on the breast were the most common,

136
Labeling of Specimens
  • 2006 study found if 16,632 specimen errors
  • 1 were mislabeled,
  • 6.3 were requisition mismatches,
  • 4.6 were unlabeled specimens,
  • Study found that strategies could be put in place
    to reduce these and improve patient safety
  • Working in interdisciplinary teams can improve
    safety and outcomes (Nov 2006, Wagar, EA, Arch
    Pathol Lab Med)
  • 2006 study found 1
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