Recommended by the Sentinel Event Alert Advisory Group NATIONAL PATIENT SAFETY GOALS FY 2008.
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Transcript of Recommended by the Sentinel Event Alert Advisory Group NATIONAL PATIENT SAFETY GOALS FY 2008.
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.