Recommended by the Sentinel Event Alert Advisory

Group

NATIONAL PATIENT NATIONAL PATIENT SAFETY GOALSSAFETY GOALS

FY 2008FY 2008

NATIONAL PATIENT SAFETY NATIONAL PATIENT SAFETY GOALS FY 2008GOALS FY 2008

Improve Accuracy of Patient Patient IdentificationIdentification

Improve Effective CommunicationCommunication Among Caregivers

Improve Safety of Using MedicationsMedications Reduce Risk of Health Care-Health Care-

Associated InfectionsAssociated Infections Accurately and Completely Reconcile Reconcile

MedicationsMedications Across Continuum of Care

NATIONAL PATIENT SAFETY NATIONAL PATIENT SAFETY GOALS FY 2008GOALS FY 2008

Reduce the Risk of Patient Harm Resulting from FallsFalls

Encourage Patient’s Active Patient’s Active InvolvementInvolvement in Their Own Care as a Patient Safety Strategy

The Organization Identifies Organization Identifies Safety Risks Inherent in its Safety Risks Inherent in its Patient PopulationPatient Population

NATIONAL PATIENT SAFETY NATIONAL PATIENT SAFETY GOALS FY 2008GOALS FY 2008

Reduce the Risk of InfluenzaInfluenza and Pneumococcal DiseasePneumococcal Disease in Institutionalized Older Adults

Prevent Health Care-Health Care-Associated PressureAssociated Pressure UlcersUlcers

NATIONAL PATIENT SAFETY NATIONAL PATIENT SAFETY GOALS FY 2008GOALS 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.

GOAL 1: Improve the Accuracy of Patient Improve the Accuracy of Patient

Identification Identification

A) Use at least two patient identifiers (not the patient’s room number) when:

Administering medications or blood products Taking blood (or other) samples for clinical

testing Providing care, treatment, procedure, or

services

Identifiers that may be used: The patient’s name Patient’s birth date Assigned identification number Patient’s Social Security number Patient’s telephone number or address Bar coding (includes two or more

indicators) Photo ID

GOAL 1: Improve the Accuracy of Patient Improve the Accuracy of Patient

Identification Identification

Identifiers used for unconscious patient: Family may verify the patient ID EMS/ Police verify the patient ID Assign John/Jane Doe

GOAL 1: Improve the Accuracy of Patient Improve the Accuracy of Patient

Identification 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 outtime out” to confirm:

correct patient correct procedure correct site

GOAL 1: Improve the Accuracy of Patient Improve the Accuracy of Patient

Identification Identification

Must use ‘active’ communication techniques by all team members

Definition of ‘active’ communication: Affirmation - orally or by some action Involves everyone’s participation

GOAL 1: Improve the Accuracy of Patient Improve the Accuracy of Patient

Identification Identification

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

A) Implement a process for taking verbal or telephone orders that

requires a verification “read backread back” of the complete order by the person receiving the order.

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

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

Record verbal/phone order directly onto order sheet in patient’s chart

Read back order to the prescriber

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

Verbal orders must contain: Patient’s 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

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

B) Standardize the abbreviations used throughout the organization, including a list of abbreviations, acronyms and symbols not to use

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

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregiversCorrect Way to Write…

Notify the nurse if you see unapproved abbreviations in use-

The “Do Not Use AbbreviationsDo Not Use Abbreviations” list is printed at the top of the MD

Order Sheets.

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

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 valuescritical test results and values

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 patient’s responsible licensed caregiver is not available within the timeframes, there is a mechanism to report the critical information to an alternate caregiver.

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

GOAL 2GOAL 2::Improve Effectiveness of Improve Effectiveness of Communication Among Communication Among

CaregiversCaregivers

E) Implement a standardized approach to “hand offhand off” communications, including an opportunity to ask and respond to questions.

GOAL 3GOAL 3: : Improve the Safety of Improve the Safety of

Using MedicationsUsing Medications

A) Standardize and

limit drug concentrations available in the organization

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

GOAL 3GOAL 3: : Improve the Safety of Improve the Safety of

Using MedicationsUsing 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.

GOAL 3GOAL 3: : Improve the Safety of Improve the Safety of

Using MedicationsUsing Medications

GOAL 4GOAL 4::Reduce the Risk of Reduce the Risk of

HealthCare-Associated HealthCare-Associated InfectionsInfections

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.

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.

GOAL 5GOAL 5::Accurately and Completely Reconcile Accurately and Completely Reconcile Medications Across the Continuum of Medications Across the Continuum of

CareCare

B) A complete list of the patient’s 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.

GOAL 5GOAL 5::Accurately and Completely Reconcile Accurately and Completely Reconcile Medications Across the Continuum of Medications Across the Continuum of

CareCare

GOAL 5GOAL 5::Accurately and Completely Reconcile Accurately and Completely Reconcile Medications Across the Continuum of Medications Across the Continuum of

CareCare

The complete list of medications is also provided to the patient on discharge from the facility.

C)

GOAL 5GOAL 5::Accurately and Completely Reconcile Accurately and Completely Reconcile Medications Across the Continuum of Medications Across the Continuum of

CareCare

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.

A) 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

GOAL 6GOAL 6:Reduce the Risk of Patient Harm Reduce the Risk of Patient Harm

Resulting from FallsResulting from Falls

B) Implement a fall reduction program, including a transfer protocol, and evaluate the effectiveness of this program

GOAL 6GOAL 6::Reduce the Risk of Patient Harm Reduce the Risk of Patient Harm

Resulting from FallsResulting from Falls

Define and communicate the means for patients and

their families to report concerns about safety, and encourage them to do so.

GOAL 7GOAL 7::Encourage Patient’s Active Encourage Patient’s Active

Involvement in Their Own Care as Involvement in Their Own Care as a Patient Safety Strategya Patient Safety Strategy

GOAL 7GOAL 7::Encourage Patient’s Active Encourage Patient’s Active

Involvement in Their Own Care as Involvement in Their Own Care as a Patient Safety Strategya Patient Safety Strategy

The organization identifies patients at risk for suiciderisk for suicide.

[Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.]

GOAL 8GOAL 8::The Organization Identifies Safety The Organization Identifies Safety

Risks Inherent in its Patient Risks Inherent in its Patient PopulationPopulation

GOAL 9GOAL 9::Reduce the Risk of Influenza & Reduce the Risk of Influenza &

Pneumococcal Pneumococcal Disease in Institutionalized Older Disease in Institutionalized Older

AdultsAdults

Goal #9 pertains specifically to the following populations:

a.) Assisted Livingb.) Disease-Specific Carec.) Long Term Care

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

GOAL 9GOAL 9::Reduce the Risk of Influenza & Reduce the Risk of Influenza &

Pneumococcal Pneumococcal Disease in Institutionalized Older Disease in Institutionalized Older

AdultsAdults

C) Develop and implement a protocol to identify new cases of influenza and to manage an outbreak

GOAL 9GOAL 9::Reduce the Risk of Influenza & Reduce the Risk of Influenza &

Pneumococcal Pneumococcal Disease in Institutionalized Older Disease in Institutionalized Older

AdultsAdults

GOAL 10GOAL 10 : : Prevent Health Care-Associated Prevent Health Care-Associated

Pressure UlcersPressure 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.

GOAL 11GOAL 11::Reduce the Risk of Surgical FiresReduce the Risk of Surgical Fires

Goal #11 pertains to the following settings:

a.) Ambulatory Surgeryb.) Office-Based Surgery

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

GOAL 11GOAL 11::Reduce the Risk of Surgical FiresReduce the Risk of Surgical Fires

NATIONAL PATIENT SAFETY NATIONAL PATIENT SAFETY GOALS FY 2008GOALS 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.