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National Patient Safety Goals

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Title: National Patient Safety Goals


1
National Patient Safety Goals
  • Peter Angood MD FACS FCCM
  • Vice President Chief Patient Safety Officer
  • Joint Commission (JCAHO)

2
The Joint CommissionsSentinel Event Policy
  • Established in January 1996 with the following
    goals
  • To have a positive impact in improving care
  • To focus attention on underlying causes and risk
    reduction
  • To increase the general knowledge about sentinel
    events, their causes and prevention
  • To maintain public confidence in the
    accreditation process

3
Joint Commission Public Policy Position on
Reporting Managing Medical Errors
  • In order to measurably improve patient safety,
    the Joint Commission supports
  • Creation of an effective national reporting
    system
  • (mandatory or voluntary)
  • Conditioned on the following
  • Standardized definition of a reportable medical
    error or event
  • Requirement for in-depth analysis of each
    error/event
  • Federal protection from disclosure of the
    resulting information
  • Requirement for action plan with follow-up
  • Sharing of event-related information with
    oversight bodies

4
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)
  • Event resulted in unanticipated patient death or
    major permanent loss of function (unrelated to
    the natural course of the patient's illness or
    underlying condition)
  • OR

5
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)
  • Or, the event involves one of the following
  • Suicide in a round-the-clock staffed care setting
    or within 72 hours of discharge
  • Abduction of a patient (any age)
  • Infant discharge to wrong family
  • Rape
  • Hemolytic transfusion reaction
  • Surgery on wrong patient or wrong body part

6
Sentinel Events Subject to Review Under the
Sentinel Event Policy
(Applies only to recipients of care)
  • Or, the event involves one of the following
  • Unintended retention of a foreign object after
    surgery
  • Severe neonatal hyperbilirubinemia
  • (gt30 milligrams/deciliter)
  • Radiation overdose
  • Fluoroscopy gt 1500 rad to a single field
  • Radiotherapy to the wrong body region or gt25
    above the planned dose

7
Sentinel Event Experience to Date
Of 3548 sentinel events reviewed by the Joint
Commission, January 1995 through December 2005
  • 464 inpatient suicides
  • 455 events of surgery at the wrong site
  • 444 operative/post op complications
  • 358 events relating to medication errors
  • 269 deaths related to delay in treatment
  • 189 patient falls
  • 138 deaths of patients in restraints
  • 121 assault/rape/homicide
  • 109 perinatal death/injury
  • 94 transfusion-related events
  • 67 infection-related events
  • 66 deaths following elopement
  • 65 fires
  • 58 anesthesia-related events
  • 651 other

3548 RCAs
8
Percent of Events That Were Self-Reported (by
State)
9
Root Causes of Sentinel Events
(All categories 1995-2004)
Percent of 2966 events
10
Root Causes of Sentinel Events
(All categories 2005)
Percent of 582 events
11
(No Transcript)
12
Sentinel Event Alert
  • Potassium chloride
  • Policy issues
  • Policy issues
  • Policy issues
  • Policy issues
  • Wrong site surgery
  • Suicide
  • Restraint deaths
  • Infant abductions
  • Transfusion errors
  • High Alert Medications
  • Op/post-op complications
  • Impact of SE Alert
  • Fatal falls
  • Infusion pumps
  • Proactive risk reduction
  • Home fires (O2 therapy)
  • Kernicterus
  • Look-alike, sound-alike drugs
  • Kreutzfeldt-Jakob disease
  • Medical gas mix-ups
  • Needles sharps injuries
  • Dangerous abbreviations
  • Wrong-site surgery 2
  • Ventilator-related events
  • Delays in treatment
  • Bed rail deaths injuries
  • Nosocomial infections
  • Surgical fires
  • Perinatal deaths
  • Anesthesia awareness
  • Kernicterus 2
  • PCA by proxy
  • Intrathecal vincristine
  • Medication reconciliation
  • Tubing misconnections
  • Emergency power failures

13
National Patient Safety Goals
  • Each year, a set of Goals will be identified from
    topics published in Sentinel Event Alert
  • A small number of specific requirements for each
    of the Goals will be identified for survey the
    following year
  • The Goals and their requirements will be
    published by mid-year
  • Selection of the Goals and requirements will be
    guided by a panel of experts the Sentinel Event
    Advisory Group

14
The Sentinel Event Advisory Group
  • Nationally recognized experts in patient safety
  • Systems engineers with practical knowledge of
    root cause analysis, failure mode effects
    analysis, human factors engineering, etc.
  • Individuals with hands-on experience in health
    care organizations, representative of the types
    sizes of organizations and the various patient
    populations
  • Experts in related fields such as
    pharmaceuticals, information technology, medical
    equipment, etc.
  • Ad hoc appointments for special expertise

15
The Sentinel Event Advisory Group
  • Assess the evidence for and face validity of
    Sentinel Event Alert recommendations
  • Assess the practicality and cost of implementing
    each of the identified evidence-based
    recommendations
  • Reach consensus on candidates for National
    Patient Safety Goals
  • Assess the comparability of alternatives to the
    NPSG requirements that are implemented by
    individual organizations
  • Advise on future topics for Sentinel Event Alert

16
The Joint Commission 2005National Patient Safety
Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery
  • Infusion pumps
  • Clinical alarm systems
  • Health care-associated infections
  • Reconciliation of medications
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • NPSG implementation by network components

17
The Joint Commission 2006National Patient Safety
Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery (Universal Protocol)
  • Health care-associated infections
  • Reconciliation of medications
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • Patient involvement
  • Pressure ulcers

18
NPSG Compliance Data for 20032006(General
Hospital Full Surveys Percent Non-compliance)
19
Requesting Review of an Alternative Approach
  • Requests for review of an alternative approach to
    one of the NPSG requirements must be submitted
    prior to survey
  • Request form and procedure available on
    www.jcaho.org
  • Review by Sentinel Event Advisory Group
  • Decision by the Joint Commission on acceptability
    of the alternative approach
  • Evaluation of implementation by surveyor

20
Alternatives Approaches to the NPSGs
21
The JCAHO 2006National Patient Safety Goals
  • The 2006 Goals and associated requirements were
    approved by the Board of Commissioners on May 20,
    2005
  • Keep the focusNo more than two new requirements
    per program
  • High impact
  • Evidence-based
  • Cost-effective
  • No increase in the total number of requirements

22
Moving from 2005 to 2006
  • Retire, modify or transition some 2005 goals
  • 1a, 1b, 2aContinue in 2006 no change
  • 2bContinue with changes per Summit
  • 2c, 2dModify (timely communication between
    providers delete directly)
  • 3aRetire (covered in Med Use standards)
  • 3bContinue implement Rule-of-6 transition plan
  • 3cContinue in 2006 no change
  • 4a, 4b, 5a, 6a, 6bRetire (covered in U.P. and EC
    standards)
  • 7a, 7bContinue in 2006 no change
  • 8a, 8bMove from planning to implementation
  • 9aRetire (replace with 9b)
  • 10a,b,c 11a, 12aContinue in 2006 no change

23
New Goals Requirements for 2006
  • Add to Goal 2 Hand-off communication
  • (All programs)
  • Add to Goal 3 Label meds on sterile field
  • (Hospitals, Ambulatory, Office-based Surgery)
  • New Goal 13 Patient involvement in safety
  • (Home Care, Lab, Assisted Living, DSC)
  • New Goal 14 Pressure ulcer prevention
  • (Long Term Care)

24
The Joint Commission 2006National Patient Safety
Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery Universal Protocol
  • Infusion pumps
  • Clinical alarm systems
  • Health care-associated infections
  • Medication reconciliation
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • NPSG implementation by network components
  • Patient involvement
  • Pressure ulcers

25
The Joint Commission 2007National Patient Safety
Goals
  • Patient identification
  • Communication among caregivers
  • Medication safety
  • Wrong-site surgery (Universal Protocol)
  • Health care-associated infections
  • Reconciliation of medications
  • Patient falls
  • Flu pneumonia immunization
  • Surgical fires
  • Patient involvement
  • Pressure ulcers
  • Identify safety risks inherent in patient
    population

26
Implementation Expectations and FAQs
  • Implementation Expectations
  • Rationale
  • Performance expectations requirements
  • FAQs
  • Interpretation of terms, scope, applicability
  • Suggestions and recommendations for how to
  • Self-assessment and survey process insights

27
National Patient Safety Goals
  • Goal 1 Improve the accuracy of patient
    identification.
  • Requirement 1.a.
  • Use at least 2 patient identifiers (not the
    patients room number) whenever administering
    medications or blood products taking blood
    samples and other specimens for clinical testing
    or providing any other treatments or procedures.
  • Requirement 1.b. (Universal Protocol)
  • Prior to the start of any surgical or invasive
    procedure, conduct a verification time out to
    confirm the correct patient, procedure, and site.

28
National Patient Safety Goals
  • Goal 1 Improve the accuracy of patient
    identification.
  • Requirement 1.a. For Laboratories only
  • Use at least two patient identifiers (neither to
    be the patient's location) whenever collecting
    laboratory samples or administering medications
    or blood products, and use two identifiers to
    label sample collection containers in the
    presence of the patient. Processes are
    established to maintain samples' identity
    throughout the pre-analytical, analytical and
    post-analytical processes.

29
National Patient Safety Goals
  • Goal 1 Improve the accuracy of patient
    identification.
  • Requirement 1.b. For Laboratories only
  • Immediately prior to the start of any invasive
    procedure, conduct a final verification process
    to confirm the correct patient, procedure, site,
    and availability of appropriate documents. This
    verification process uses activenot
    passivecommunication techniques. The patient's
    identity is re-established if the practitioner
    leaves the patient's location prior to initiating
    the procedure. Marking the site is required
    unless the practitioner is in continuous
    attendance from the time of the decision to do
    the procedure and patient consent to the
    initiation of the procedure (for example, bone
    marrow collection, or fine needle aspiration).

30
National Patient Safety Goals
  • Goal 2 Improve the effectiveness of
    communication among caregivers.
  • Requirement 2.a.
  • For verbal or telephone orders or for telephonic
    reporting of critical test results , verify the
    complete order or test result by having the
    person receiving the order or test result
    read-back the complete order or test results.
  • Requirement 2.b.
  • Standardize a list of abbreviations, acronyms,
    and symbols that are not to be used throughout
    the organization.

31
Official Do Not Use list
  • u
  • IU
  • qd
  • qod
  • Leading decimal point
  • (always use a Leading zero)
  • Trailing zero
  • MS
  • MSO4
  • MgSO4

No additions for 2007
Plus an additional 3 items of the organizations
choosing
32
Recommendations from the Summit
  • Expected level of compliance
  • 100 for pre-printed forms
  • 90 for handwritten documentation in 2005
  • Annual increase in expected level of compliance
    after 2005
  • Up to maximum of 95
  • Further study needed to establish rules for
    computer-generated forms and computer displays

Approved for 2005
No change for 2006-07
33
Clarification of Orders Containing Do Not Use
Abbreviations
  • 2005 Clarification of any order containing a do
    not use abbreviation is expected
  • Problem Unintended consequence of burden on
    nurses and pharmacists prescribers not returning
    calls from pharmacy
  • 2006 New approach
  • Require clarification with the prescriber when
    the order is not clearno call required if order
    is clear
  • Use of prohibited terms is scored whenever used
  • Failure to clarify unclear orders, will be scored
    separately
  • Medical staff is responsible for managing
    prescriber behaviors (not nurses pharmacists)

34
National Patient Safety Goals
  • Goal 2 Improve the effectiveness of
    communication among caregivers.
  • Requirement 2.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.

35
Improving the Timeliness of Reporting Critical
Test Results
  • This is a performance improvement requirement
  • Measure, assess, improve (if appropriate)
  • It applies to all types of diagnostic testing
    (not just lab)
  • Critical test
  • Measure time from order to time of report
  • Critical result / value
  • Measure time from identification of critical
    result to time of report

36
Improving the Timeliness of Reporting Critical
Test Results
  • The health care organization defines
  • Its critical tests
  • Its critical results/values
  • Its target turn-around times
  • Its measurement strategies

37
National Patient Safety Goals
  • Goal 2 Improve the effectiveness of
    communication among caregivers.
  • Requirement 2.d. For Laboratories only
  • All values defined as critical by the laboratory
    are reported directly to a responsible licensed
    caregiver within time frames established by the
    laboratory (defined in cooperation with nursing
    and medical staff). When the patients
    responsible licensed caregiver is not available
    within the time frames, there is a mechanism to
    report the critical information to an alternative
    responsible caregiver.

38
National Patient Safety Goals
  • Goal 2 Improve the effectiveness of
    communication among caregivers.
  • Requirement 2.e. All programs
  • Implement a standardized approach to hand off
    communications, including an opportunity to ask
    and respond to questions.

39
Hand-off Communication
  • A hand off communication is a contemporaneous,
    interactive process of passing patient-specific
    information from one caregiver to another or from
    one team of caregivers to another for the purpose
    of ensuring the continuity and safety of the
    patients care.
  • Examples
  • Nursing change-of-shift report
  • Physician sign-out to a covering physician
  • Anesthesia provider or circulating nurse
    reporting to the PACU staff
  • ED staff communicating with staff at a receiving
    facility

40
Developing a Standardized Approach to Hand-off
Communications
  • A standardized approach should identify
  • The hand off situations that it applies to
  • Who is, or should be, involved in the
    communication
  • What information should be communicated
  • Diagnoses and current condition of the patient
  • Recent changes in condition or treatment
  • Anticipated changes in condition or treatment
  • What to watch for in the next interval of care
  • Opportunities to ask and respond to questions
  • When to use certain techniques (repeat-back
    SBAR)
  • What print or electronic information should be
    available

41
National Patient Safety Goals
  • Goal 3 Improve the safety of using
    medications.
  • Requirement 3.a. Retiredsee MM.2.20, EP 9
  • Remove concentrated electrolytes from patient
    care units (including KCl, K3PO4, NaCl gt 0.9)
  • Requirement 3.b.
  • Standardize and limit the number of drug
    concentrations available in the organization.

42
National Patient Safety Goals
  • Goal 3 Improve the safety of using
    medications.
  • Requirement 3.c.
  • Identify and, at a minimum, annually review a
    list of look-alike/sound-alike drugs used in the
    organization, and take action to prevent errors
    involving the interchange of these drugs.

43
Lists of Look-alike, Sound-alike Drugs
  • Go to www.jcaho.org
  • Click on NPSGs and FAQs
  • Then click on Hospital
  • Then click on FAQs about the 2005 NPSGs
  • Select New Look-alike, sound-alike drug list
  • An organizations list of look-alike/sound-alike
    drugs must contain a minimum of 10 drug
    combinations. At least 5 of these combinations
    must be selected from Table I or from Table II,
    as appropriate to the type of organization. An
    additional 5 combinations must be selected from
    any of the Tables I, II and/or III.

44
National Patient Safety Goals
  • Goal 3 Improve the safety of using
    medications.
  • Requirement 3.d. Hospital, Amb., OBS
  • 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.

45
Label all medications
  • See standard MM.4.30 Medications are
    appropriately labeled
  • Includes all medications and solutions
  • Even if there is only one
  • Even if it is obvious
  • It also applies to anesthesia medications
  • It applies to the O.R. and other procedural
    settings, not just invasive procedures

46
What Should Be on the Label?
  • Required by standard MM.4.30 for all settings
  • Drug name, strength, amount (if not apparent from
    the container)
  • Expiration date, when not used within 24 hours
  • Expiration time when expiration is within 24
    hours
  • For IV admixtures and parenteral nutrition
    solutions, the date prepared and diluent.
  • Additional requirements for labeling in
    perioperative/procedural settings
  • The date (of transfer and use)
  • Initials of the person preparing the label
  • Verification of label by a second person unless
    the same person prepares and uses the med /
    solution

47
National Patient Safety Goals
  • Goal 4 Eliminate wrong-site, wrong-patient,
    wrong-procedure surgery.
  • Retired Now Surveyed under the Universal
    Protocol

48
Sentinel Event TrendsWrong-site Surgeries
Reported by Year
49
Provisions of the Universal Protocol
  • Preoperative verification process
  • Relevant pre-op tasks completed and information
    is available and correct
  • Surgical site marking
  • Unambiguous mark, visible after prep drape
  • Right/left, multiple structures or levels
  • Time out immediately before starting
  • Involves entire team active communication
  • Fail-safe model No go unless all agree
  • Applicable to invasive procedures in all settings

50
Marking the Operative Site(Special
considerations)
  • Spinal surgery
  • Mark general level prior to surgery (C/T/L)
  • Mark precise level intraop using radiographic
    tech.
  • Teeth need not be marked directly
  • The dental radiograph or diagram must be marked
    and available at the time of the procedure
  • Other exemptions
  • Site not predetermined
  • Continuous attendance
  • Premature infants
  • Procedure for patient refusal of site marking

51
Time out Immediately Before Starting the
Procedure
  • In the location where the procedure will be done
  • Involve entire team using active communication
  • Must be briefly documented
  • Must include, at a minimum
  • Correct patient
  • Correct procedure
  • Correct site
  • Correct positioning
  • Correct implant(s) and special equipment
  • Process for reconciling differences

52
The JCAHO 2006National Patient Safety Goals
  • Goal 5 Improve the safety of using infusion
    pumps.
  • Retiredsee EC.6.20, EP 2

53
The JCAHO 2006National Patient Safety Goals
  • Goal 6 Improve the effectiveness of clinical
    alarm systems. Retired Surveyed under the EC
    standards EC.6.20

54
National Patient Safety Goals
  • Goal 7 Reduce the risk of health
    care-associated infections.
  • Requirement 7.a.
  • Comply with current CDC hand hygiene guidelines.
  • Requirement 7.b.
  • Manage as sentinel events all identified cases
    of unanticipated death or major permanent loss of
    function associated with a health care-associated
    infection.

55
CDC Hand Hygiene Guidelines
  • Full report available at http//www.cdc.gov/handhy
    giene/
  • Specific recommendations
  • Indications for hand washing and hand antisepsis
  • Visibly soileduse soap and water
  • Not visibly soiledmay use alcohol-based hand rub
  • List of specific clinical circumstances
  • Towelettes are not a substitute
  • Non-alcohol-based hand rubs not recommended

56
CDC Hand Hygiene Guidelines
  • Specific recommendations (contd.)
  • Hand hygiene technique
  • Alcohol-based hand rubuntil dry
  • Soap waterat least 15 seconds
  • Surgical hand antisepsis
  • Selection of hand hygiene agents
  • Skin care
  • Other aspects of hand hygiene

57
CDC Hand Hygiene Guidelines
  • Each CDC hand hygiene recommendation cites the
    strength of evidence supporting the
    recommendation
  • Category I (IA, IB, or IC)
  • Category II
  • Under Goal 7a, implementation of all CDC hand
    hygiene recommendations supported by Category I
    evidence will be required.
  • Organizations will be asked to consider
    implementing all CDC hand hygiene recommendations
    supported by Category II evidence.

58
CDC Hand Hygiene Guidelines
  • Compliance expectation
  • Satisfactory compliance
  • at least 90 compliance with Level I CDC hand
    hygiene recommendations throughout the
    organization

59
National Patient Safety Goals
  • Goal 7 Reduce the risk of health care-acquired
    infections.
  • Requirement 7.a.
  • Comply with current CDC hand hygiene guidelines.
  • Requirement 7.b.
  • Manage as sentinel events all identified cases
    of unanticipated death or major permanent loss of
    function even if associated with a health
    care-acquired infection.

60
Healthcare-Associated Infection and Sentinel
Events
  • This is not a new requirement
  • Any unanticipated death or major injury is a
    sentinel event whether there is an infection or
    not
  • No change in surveillance methods is required
  • This does not replace traditional rate-based
    analysis of health care-acquired infections
  • RCA is not required for all health care-acquired
    infections only those that result in death or
    major injury
  • The RCA looks comprehensively at the care of the
    patient, not just the infection
  • See http//www.apic.org for Integrating sentinel
    event analysis into your infection control
    practice

61
National Patient Safety Goals
  • Goal 8 Accurately and completely reconcile
    medications across the continuum of care.
  • Requirement 8.a.
  • Implement a process for obtaining and
    documenting a complete list of the patient's
    current medications upon the patient's 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.
  • Requirement 8.b.
  • A complete list of the patient's medications 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. The complete
    list is also provided to the patient on discharge.

New !
62
Why Is Medication Reconciliation Important?
  • The most frequently occurring type of medical
    error
  • Medication errors
  • The most frequently cited category of root causes
    for serious adverse events
  • Ineffective communication
  • The most vulnerable parts of a process
  • Links between the steps (the hand-offs)
  • Medication reconciliation addresses all of these

63
Which Medications Must Be Reconciled?
  • Medication includes
  • Prescription medications
  • Sample medications
  • Vitamins
  • Nutriceuticals
  • Over-the-counter drugs
  • Vaccines
  • Diagnostic and contrast agents
  • Radioactive medications
  • Respiratory therapy-related medications
  • Parenteral nutrition
  • Blood derivatives
  • Intravenous solutions (plain or with additives)
  • Any product designated by the FDA as a drug

64
What Should Be on the Home Med List?
  • Medications on the home med list typically
    include
  • Prescription medications
  • Sample medications
  • Vitamins
  • Nutriceuticals
  • Over-the-counter drugs
  • Respiratory therapy-related medications
  • For each medication, the list should include
  • Name of the medication
  • Dose
  • Route
  • Frequency
  • Last dose (if patient is to be admitted)

Include all current medications. This is not a
medication history.
65
Steps in the Reconciliation Process
  • Develop a complete and accurate list of the
    patients medications (Not new see MM.1.10)
  • Compare (reconcile) the listed medications with
    any new orders for medications
  • Omission
  • Duplication
  • Interaction
  • Name/dose/route confusion
  • Update the list as orders change during the
    episode of care
  • Communicate the updated list to the next
    provider(s) of care

66
When Should Reconciliation Occur?
  • Whenever the organization
  • refers or transfers a patient to another
    setting, service, practitioner, or level of care
    within or outside the organization.
  • At a minimum
  • Any time the organization requires that orders
    be rewritten
  • Any time the patient changes service, setting,
    provider or level of care and new medication
    orders are written
  • For transitions not involving new medications or
    rewriting of orders, the organization determines
    whether reconciliation must occur.

67
What About Minimal Medication Use Scenarios?
  • Brief outpatient encounter (e.g., ED, Xray)
  • No new meds prescribed for use after discharge
  • No changes to the patient's current meds
  • Minimal medication use during encounter
  • Act locally with minimal systemic activity
  • Examples
  • Minimally absorbed topical agents
  • Low volume local infiltration anesthetics
  • Non-absorbable enteric contrast agents
  • Should the Med Rec process be different?

68
How Many Lists Do We Need?
  • An initial home medication list
  • Keep this handydont change it.
  • A list of medications that is updated throughout
    the episode of care
  • This corresponds to what is on the M.A.R.
  • Which list do we use for reconciliation? Both!
  • Remember, some home medications may be held
    when a patient is admitted or goes to surgery.
    They may need to be resumed upon transfer to a
    different level of care, return from the OR, or
    at discharge.

69
Whats on the list and who gets it?
  • Requirement 8.b.
  • A complete list of the patient's medications is
  • communicated to the next provider of service
  • when the organization refers or transfers a
  • patient to another setting, service,
    practitioner
  • or level of care within or outside the
    organization.
  • Whats on the list?
  • All the medications the patient is to be taking
    after discharge, including dosage, frequency, and
    route.
  • Who gets the list?
  • The next provider of care
  • The patient

70
Discharge Orders, Instructions, Lists
  • Discharge orders
  • Directed to other caregivers (treatments, Rx)
  • Blanket orders (resume all ) are prohibited
  • Discharge instructions
  • Directed to the patient (self-care)
  • Resume home meds is permitted
  • Discharge list of medications
  • Complete list of continuing medications
  • This is not an order previous medications do not
    need to be reordered

71
Barriers to Implementation
  • Physician buy-in
  • Engage medical staff leaders early in the
    development process
  • Demonstrate value, not just in terms of patient
    safety but in efficiency for the practitioners
  • Provide feedback on good catches
  • Just another add-on activity
  • Integrate the Med Rec process into the existing
    work flow
  • Its not my job
  • Make it a team activity with clear
    responsibilities for each of the steps in the
    process

72
The JCAHO 2006National Patient Safety Goals
  • Goal 9 Reduce the risk of patient harm
    resulting from falls.
  • Requirement 9.a. Retired
  • Assess and periodically reassess each patient's
    risk for falling, including the potential risk
    associated with the patient's medication regimen,
    and take action to address any identified risks.
  • Requirement 9.b. Replaces 9.a.
  • Implement a fall reduction program, including a
    transfer protocol, and evaluate the effectiveness
    of the program.

73
Fall Reduction Program
  • Include, as appropriate to the setting and
    patient population
  • Individual patient assessment and periodic
    reassessment
  • Consideration of the patients medication regimen
  • Assessment of the environment of care
  • Modifications to the environment of care
  • Transfer protocols
  • Alarm systems
  • Staff orientation training

74
National Patient Safety Goals
  • Goal 10 Reduce the risk of influenza and
    pneumo-coccal disease in older adults. LTC
    AL, only
  • Requirement 10.a.
  • Develop and implement a protocol for
    administration and documentation of the flu
    vaccine.
  • Requirement 10.b.
  • Develop and implement a protocol for
    administration and documentation of the
    pneumococcus vaccine.
  • Requirement 10.c.
  • Develop and implement a protocol to identify new
    cases of influenza and to manage an outbreak.

75
National Patient Safety Goals
  • Goal 11 Reduce the risk of surgical fires.
  • Requirement 11.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.
  • AHC and OBS, only.

76
National Patient Safety Goals
  • Goal 12 Implementation of applicable National
    Patient Safety Goals and associated requirements
    by components and practitioner sites.
    Networks PPOs, only
  • Requirement 12.a.
  • Inform and encourage components and practitioner
    sites to implement the applicable National
    Patient Safety Goals and associated requirements.

Also, see hospital standard LD.3.50 Services
provided by consultation, contractual
arrangements, or other agreements are provided
safely and effectively.
77
National Patient Safety Goals
  • Goal 13 Encourage the active involvement of
    patients and their families in the patients care
    as a patient safety strategy. AL, DSC, HC, Lab
  • Requirement 13.a.
  • Define and communicate the means for patients to
    report concerns about safety and encourage them
    to do so.
  • For 2007 Ambulatory, behavioral health care,
    critical access hospital, hospital, long term
    care office-based surgery

New !
78
National Patient Safety Goals
  • Goal 14 Prevent health care-associated
    pressure ulcers (decubitus ulcers). LTC
    only
  • Requirement 14.a.
  • Assess and periodically reassess each residents
    risk for developing a pressure ulcer and take
    action to address any identified risks.

79
Moving to the 2007 JCAHONational Patient Safety
Goals
  • Goal 15 The organization identifies safety
    risks inherent in its patient population
  • Requirement 15.a.
  • the organization identifies patients at risk for
    suicide BHC, HAP
  • Requirement 15.b.
  • the organization identifies risks associated with
    long-term oxygen therapy such as home fires Home
    care

New !
80
Surveying and Scoring theNational Patient Safety
Goals
  • Must implement all applicable Goals
    Requirements or implement an acceptable
    alternative approach(es)
  • Evaluated in the PPR and during all full
    accreditation surveys and for-cause surveys
  • Surveyors evaluate actual performance, not just
    intent
  • Failure to comply with one or more requirements
    of a Goal will result in a Requirement for
    Improvement
  • NPSG requirements that are also in the standards
    will only be scored once (no double jeopardy)

81
Survey and Scoring Method for Requirements 2b and
7a
  • All NPSG requirements are pass/failno partial
    compliance
  • Three observation rule is used by surveyors for
    2b and 7a
  • For Requirement 2b, one observation one or
    more slips per clinician per record
  • For Requirement 7a, one observation any
    instance of non-compliance with a CDC category I
    recommendation
  • Three observations a Requirement for Improvement

82
Public Disclosure of Compliance with the National
Patient Safety Goals
  • Aggregate data
  • Data from 2003 - 2005 surveys posted on Joint
    Commission web site
  • Individual health care organizations
  • Compliance with specific requirements
  • Revised Quality Reports
  • on web site since mid-year 2004

83
Additional Topics Being Considered for 2008
Implementation
  • Comprehensive risk assessment
  • Scope of this assessment to be program-specific
  • Manage disruptive behavior
  • Contract worker orientation training
  • Anticoagulant management
  • Intravascular catheter infections
  • Expand scope of certain existing requirements
  • Pressure ulcer prevention
  • Patient involvement
  • Surgical fires

84
Patient Safety and Quality Improvement Act of 2005
  • To encourage a culture of safety through legal
    protection of patient safety information
    voluntarily reported to PSOs.
  • Patient safety organization (PSO)
  • Duties
  • Eligibility criteria and certification
  • HIPAA considerations Business associate
  • Patient safety work product (PSWP)
  • PSWP is privileged and confidential
  • National Network of patient safety databases
  • Report to HHS IOM Effectiveness study by GAO

85
For more information
  • The Joint Commission Web Site
  • www.jointcommission.org
  • Joint Commission International Web Site
  • www.jointcommissioninternational.org
  • Joint Commission International Center for Patient
    Safety
  • www.jcipatientsafety.org
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