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Recommended by the Sentinel Event Alert Advisory Group

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NATIONAL PATIENT SAFETY GOALS FY 2008 Recommended by the Sentinel Event Alert Advisory Group – PowerPoint PPT presentation

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Title: Recommended by the Sentinel Event Alert Advisory Group


1
NATIONAL PATIENT SAFETY GOALS FY 2008
  • Recommended by the Sentinel Event Alert Advisory
    Group

2
NATIONAL PATIENT SAFETY GOALS FY 2008
  • Improve Accuracy of Patient Identification
  • Improve Effective Communication Among Caregivers
  • Improve Safety of Using Medications
  • Reduce Risk of Health Care-Associated Infections
  • Accurately and Completely Reconcile Medications
    Across Continuum of Care

3
NATIONAL PATIENT SAFETY GOALS FY 2008
  • Reduce the Risk of Patient Harm Resulting from
    Falls
  • Encourage Patients Active Involvement in Their
    Own Care as a Patient Safety Strategy
  • The Organization Identifies Safety Risks Inherent
    in its Patient Population

4
NATIONAL PATIENT SAFETY GOALS FY 2008
  • Reduce the Risk of Influenza and Pneumococcal
    Disease in Institutionalized Older Adults
  • Prevent Health Care-Associated Pressure Ulcers

5
NATIONAL PATIENT SAFETY GOALS FY 2008
  • Health Care Organizations are required to
    demonstrate how the organization is meeting the
    patient Safety Goals.
  • This CBL will explain the compliance requirements
    for each of the Safety Goals.

6
GOAL 1 Improve the Accuracy of Patient
Identification
  • A) Use at least two patient identifiers (not
    the patients room number) when
  • Administering medications or blood products
  • Taking blood (or other) samples for clinical
    testing
  • Providing care, treatment, procedure, or services

7
GOAL 1 Improve the Accuracy of Patient
Identification
  • Identifiers that may be used
  • The patients name
  • Patients birth date
  • Assigned identification number
  • Patients Social Security number
  • Patients telephone number or address
  • Bar coding (includes two or more indicators)
  • Photo ID

8
GOAL 1 Improve the Accuracy of Patient
Identification
  • Identifiers used for unconscious patient
  • Family may verify the patient ID
  • EMS/ Police verify the patient ID
  • Assign John/Jane Doe

9
GOAL 1 Improve the Accuracy of Patient
Identification
  • B) JCAHO requires three items be verified
    prior to the start of any invasive or surgical
    procedure
  • Conduct a final verification process such as
    time out to confirm
  • correct patient
  • correct procedure
  • correct site

10
GOAL 1 Improve the Accuracy of Patient
Identification
  • Must use active communication techniques by all
    team members
  • Definition of active communication
  • Affirmation - orally or by some action
  • Involves everyones participation

11
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • A) Implement a process for taking verbal or
    telephone orders that requires a verification
    read back of the complete order by the person
    receiving the order.

12
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • Write purpose of the medication
  • Implement policy for verbal or telephone orders
  • Provide generic and brand names on all medication
    labels
  • Provide patient written information about their
    drugs

13
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • Record verbal/phone order directly onto order
    sheet in patients chart
  • Read back order to the prescriber

14
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • Verbal orders must contain
  • Patients name
  • Medication specifics
  • 1. Name of drug
  • 2. Dose
  • 3. Route
  • 4. Frequency
  • 5. Duration (if applicable)
  • 6. Purpose of medication (if given as
    prn)
  • 7. Any additional instructions

15
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • B) Standardize the abbreviations used
    throughout the organization, including a list of
    abbreviations, acronyms and symbols not to use

16

GOAL 2 Improve Effectiveness of Communication
Among Caregivers
Correct Way to Write
  • DO NOT USE
  • U - - - - - - - - - - - - - - - -
    Unit
  • IU - - - - - - - - - - - - - - -
    International Unit
  • MS - - - - - - - - - - - - - - -
    Morphine Sulfate
  • MgSO4 - - - - - - - - - - - -
    Magnesium Sulfate
  • MSO4 - - - - - - - - - - - - -
    Morphine Sulfate
  • QD - - - - - - - - - - - - - - -
    Every Day
  • QOD or qod - - - - - - - - -
    Every Other Day
  • X.0 mg (trailing zero)- - - -
    X mg
  • .X mg (leading zero)- - - - -
    0.X mg

17
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • Notify the nurse if you see unapproved
    abbreviations in use-
  • The Do Not Use Abbreviations list is printed at
    the top of the MD Order Sheets.

18
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • C) Measure, assess, and if appropriate, take
    action to improve the timeliness of reporting,
    and the timeliness of receipt by the responsible
    licensed caregiver, of critical test results and
    values

19
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • D) All values defined as critical by the
    laboratory are reported directly to a responsible
    licensed caregiver within timeframes established
    by the organization. When the patients
    responsible licensed caregiver is not available
    within the timeframes, there is a mechanism to
    report the critical information to an alternate
    caregiver.

20
GOAL 2 Improve Effectiveness of Communication
Among Caregivers
  • E) Implement a standardized approach to hand
    off communications, including an opportunity to
    ask and respond to questions.

21
GOAL 3 Improve the Safety of Using Medications
  • A)
  • Standardize and limit drug concentrations
    available in the organization

22
GOAL 3 Improve the Safety of Using Medications
  • B) Identify and, at a minimum, annually review
    a list of look-alike, sound-alike drugs used in
    the organization, and to take action to prevent
    errors involving the interchange of these drugs

23
GOAL 3 Improve the Safety of Using Medications
  • C) Label all medications, medication
    containers (e.g., syringes, medicine cups,
    basins), or other solutions on and off the
    sterile field in perioperative and other
    procedural settings.

24
GOAL 4 Reduce the Risk of HealthCare-Associated
Infections
  • Comply with current CDC hand-hygiene guidelines
    (contained within Infection Control CBL)
  • Manage as sentinel events all identified cases of
    unanticipated death or permanent loss of function
    associated with a health care-associated
    infection.

25
GOAL 5 Accurately and Completely Reconcile
Medications Across the Continuum of Care
  • A) Implement a process for obtaining and
    documenting a complete list of the patients
    current medications upon the patients admission
    to the organization and with the involvement of
    the patient. This process includes a comparison
    of the medications the organization provides to
    those on the list.

26
GOAL 5 Accurately and Completely Reconcile
Medications Across the Continuum of Care
  • B) A complete list of the patients medication
    is communicated to the next provider of service
    when it refers or transfers a patient to another
    setting, service, practitioner or level of care
    within or outside the organization.

27
GOAL 5 Accurately and Completely Reconcile
Medications Across the Continuum of Care
  • The complete list of medications is also
    provided to the patient on discharge from the
    facility.

C)
28
GOAL 5 Accurately and Completely Reconcile
Medications Across the Continuum of Care
Completion of a Computer-Based Learning Program
devoted to the Medication Reconciliation process
will be required of staff who are responsible for
administration of medications.
29
GOAL 6 Reduce the Risk of Patient Harm
Resulting from Falls
  • A) Assess and periodically reassess each
    patients risk for falling, including the
    potential risk associated with the patients
    medication regimen, and take action to address
    any identified risks

30
GOAL 6 Reduce the Risk of Patient Harm
Resulting from Falls
  • B) Implement a fall reduction program,
    including a transfer protocol, and evaluate the
    effectiveness of this program

31
GOAL 7 Encourage Patients Active Involvement in
Their Own Care as a Patient Safety Strategy
  • Define and communicate the means for patients and
    their families to report concerns about safety,
    and encourage them to do so.

32
GOAL 7 Encourage Patients Active Involvement in
Their Own Care as a Patient Safety Strategy
33
GOAL 8 The Organization Identifies Safety Risks
Inherent in its Patient Population
  • The organization identifies patients at risk for
    suicide.
  • Applicable to psychiatric hospitals and
    patients being treated for emotional or
    behavioral disorders in general hospitals.

34
GOAL 9 Reduce the Risk of Influenza
Pneumococcal Disease in Institutionalized Older
Adults
  • Goal 9 pertains specifically to the following
    populations
  • a.) Assisted Living
  • b.) Disease-Specific Care
  • c.) Long Term Care

35
GOAL 9 Reduce the Risk of Influenza
Pneumococcal Disease in Institutionalized Older
Adults
  • A) Develop and implement a protocol for
    administration and documentation of the flu
    vaccine
  • B) Develop and implement a protocol for
    administration and documentation of the
    pneumococcus vaccine

36
GOAL 9 Reduce the Risk of Influenza
Pneumococcal Disease in Institutionalized Older
Adults
  • C) Develop and implement a protocol to identify
    new cases of influenza and to manage an outbreak

37
GOAL 10 Prevent Health Care-Associated
Pressure Ulcers
  • Most pressure ulcers can be prevented.
  • Deterioration at Stage 1 can be halted.
  • Teach staff to reduce incidence.
  • Assess patients using Braden Scale to identify
    patients at risk and provide nutritional support
    when needed.
  • Increase activity and mobility of patients.
  • Reposition patients while avoiding shear and
    friction injury.

38
GOAL 11 Reduce the Risk of Surgical Fires
  • Goal 11 pertains to the following settings
  • a.) Ambulatory Surgery
  • b.) Office-Based Surgery

39
GOAL 11 Reduce the Risk of Surgical Fires
  • A) Educate staff, including operating licensed
    independent practitioners and anesthesia
    providers, on how to control heat sources and
    manage fuels, and establish guidelines to
    minimize oxygen concentration under drapes

40
NATIONAL PATIENT SAFETY GOALS FY 2008
  • To complete requirements for this course you must
    now click on the Take Test icon located at the
    upper left corner of the computer screen.
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