2009 National Patient Safety Goals JCC Quarterly Report October 8, 2009

Transcription

1 2009 National Patient Safety Goals JCC Quarterly Report October 8, 2009 Updated 10/08/09 J. Kosewic IMPROVE THE ACCURACY OF PATIENT IDENTIFICATION GOAL 1 Implementation Expectation Coordinator(s) NPSG Two Patient Identifiers Used when Administering Medications Nursing Directors 2nd Quarter 2009: 98% used two identifiers in 1589 out of 1616 medications pass observations The Medication Pass Observational audits conducted in all nursing units where medications are administered. One of the indicators assesses the use of two patient identifiers prior to a dose of medicine being administered. Staff members are aware that they are observed. Two Patient Identifiers are Used when: - Administering Blood Products - Collection of Blood Samples - Patient s room number or Location is not used as an Identifier - Containers used for blood and Other specimens are labeled in the presence of the patient Ebi Feibig : 100% (60/60) 2nd Quarter 2009: 100% (14/14) Specimen labeling observation audits were randomly conducted in the ICU, ED, 6G and of the phlebotomy team who collect blood specimens. Two Patient identifiers used when providing other treatments or procedures. Terry Dentoni 2nd Quarter 2009: 100% (353/353) Universal protocol audits done in all procedural areas examining patient identification is completed prior to the start of any invasive procedure. The reporting areas include: 1N, 3D, 4A, 4B, 4C, 4D, 4E, 4M, 5A, 5B, 5C, 5D, 5E/R, 5M, 6A, 6C, 6G, 6H, 6M, 7D, Cath Lab, PACU, and PHP. NPSG Eliminate transfusion error related to misidentification. Prior to initiating a blood or blood Ebi Feibig March through May 2009: 98% (40/41) Direct Observation of Transfusion (DOT) audits are conducted by Blood Bank and Nursing staff that follow a unit of blood from the blood bank to the patient and assess the unit staff compliance 1

2 component transfusion, the patient is objectively matched to the blood or blood component during a twoperson bedside verification process -one person conducting the ID verification is a qualified transfusionist -the second individual conducting the ID verification is qualified to participate in the process. IMPROVE THE EFFECTIVENESS OF COMMUNICATION AMONG CAREGIVERS. Goal 2 with the patient identification and blood transfusion policy. NPSG For verbal or telephone orders or for telephonic reporting of critical test results, the individual giving the order or test result verifies the complete order or test result by having the person receiving the information record and read back the complete order or test result. John Luce Sue Schwartz Frank Kuziel January 2009: Verbal Orders = 0 Telephone Orders = 3 (133 orders reviewed in 26 medical records) SFGH P&P Safe Medication Management: Ordering Policy and Procedure states that verbal orders are accepted in emergent situations, for pain management, or situations that a delay would adversely affect the patient. QM and Medical Record Staff auditing in 3 rd Quarter to report in 4 th Quarter NPSG There is a standardized list of abbreviations, acronyms, symbols, acronyms, symbols and dose designations that are not to be used throughout the organization. Sue Schwartz John Luce Elaine Coleman 98% (122/124) DNU not present 3 rd Quarter % (76/90) qhs and qd were the main abbreviations found in the MD Progress notes H&P section. SFGH has developed and implemented a standardized list of "Do Not Use" abbreviations. If a DNU abbreviation is found in the medical record, the auditor sends a letter to the writer from the SFGH Chief of Staff along with a copy of their documentation as well as the SFGH DNU abbreviation policy. Medical records are reviewed weekly and reported quarterly to PIPS. July DNU results discussed at the Medicine QI Committee. Strategies implemented for staff education and improved compliance. 2

3 NPSG Measure, assess and, if needed, take action to improve the timeliness of reporting and the timeliness of receipt of critical tests and critical results and values by the responsible licensed caregiver. Ebi Feibig Jacquie Caesar Clinical Lab Audit: 2008: Outpatient Areas Focus: 98.6% (142/145) Form &/or Documentation all elements in Medical Record Med-Surg: 91% (63/69) ICU: 80% (4/5) Psychiatry: 67% (4/6) ER: 10% (9/9) Amb. Clinics: 100% (11/11) Hospital policy 3.02: Communication of Critical Test Results specifies the procedures to follow regarding the reporting of critical test results. A new documentation tool has been developed that includes required elements of communicating a critical value, receipt by the responsible licensed caregiver and includes documented confirmation of receipt. Audit of Clinical lab discontinued after review their excellent compliance. : Focus audits on the critical values reporting process in areas use of the critical value form: Psychiatry and Med Surg. Mia Maka Radiology Cardiology Treadmill: 100% (1/1) ECHO: 100% (22/22) Holter: no critical Holter Results 3 rd Quarter 2009 (preliminary) Treadmill: 100% (5/5) ECHO: 100% (15/15) Holter: no critical Holter Results Head CT Acute Stroke 67% (7/11) < 60 minutes Cases not meeting target had TAT of 1-2 Hours SFGH Critical Tests Defined: Clinical Lab: Intraoperative Parathyroid. Order to Result: 45 minutes Radiology: Head CT for Stroke Order to Result: 60 minutes Anatomic Pathology: Frozen Sections Order to Result: 45 minutes Auditing focused on Anatomic Pathology Frozen Sections for Order to Result turn around time goal of 45 minutes. Pathology process and documentation improvements being tested to allow for accurate capture of frozen section specimen turn around times. Clinical Lab Intraoperative Parathyroid 89% (17/19) < 45 minute Pathology Frozen Sections 100% (38/38) < 45 minutes 3

4 NPSG The organization implements a standardized approach to hand-off communications, including an opportunity to ask and respond to questions Sue Schwartz John Luce Nursing MERT SBAR Documentation 2nd Quarter % (137/137) Hospital policy 8.03 is in place utilizing SBAR (Situation, Background, Assessment, and Recommendation); technique ensures complete communication between caregivers during patient hand-off. May 2008: IT building Handoff module for nursing documentation Nov 2008: Plan roll out of IT Handoff LCR Roll out commencing April IT system delayed spread to other units. : Med-Surg 72% (831/1153) Documented Handoff on Ticket Slip August 2009 Positive Patient ID box checked on Ticket to Ride : 75% (338/448) 2009 focus audits for handoffs with: MD, radiology transport, and nursing handoffs. Positive Patient Identification at handoff between Radiology Transport Staff and 6A Nursing Staff Ticket to Ride Pilot program where staff document handoff and transfer of critical information in SBAR. Quarter spread to all Med-Surg units. September 2009: feedback to units on areas needing improvement. IMPROVE THE SAFETY OF USING MEDICATIONS. Goal 3 NPSG Identify and annually review a list of look-alike/sound alike medications used by the organization, and take action to prevent errors involving the interchange of these medications. Fred Hom Julie Russell Nela Ponferrada Lalu Bourey December 2007 Compliant 100% (93/93) List reviewed and approved by P& T committee. Monthly refrigerator unit inspections looking for look alike, sound alike medications, including different types of insulin storage. NPSG Label all medications, medication containers (E.g. Syringes, med cups or basins) or other solutions on and off the sterile field. Fred Hom Julie Russell Nela Ponferrada Lalu Bourey Cath Lab 100% (18/18) IR 100% (1/1) Updated policy 16.32: Pharmaceutical Services: Guidelines for Preparation and Dispensing of Medications to address labeling and administration of medications 4

5 and solutions. Random observational audits of labeling syringes on the sterile field conducted. NPSG Reduce the likelihood Of patient harm associated with the use of anticoagulation therapy Christina Wang Mark Jones Mary Gray Paul Koo January 1, 2009 Fully implemented across the Anticoagulation Protocol. Education of staff on Anticoagulation Protocol M. Gray and C. Wang meeting with each Surgical service to spread the Anticoagulation Protocol continuing in Quarter Warfarin Patients 61 Pharmacist Interventions 13 instances of No baseline INR (within 24 hours of initiation Warfarin therapy) 90% (112/125) Warfarin dosing protocol adherence 158 Warfarin Patients 39 Pharmacist Interventions 14 instances of No baseline INR 99% (157/158) Warfarin dosing protocol adherence One instance lack of baseline INR drawn prior to initiation of anticoagulant therapy. (Pharmacist followed up with Provider) Monitoring of Anticoagulation Protocol through daily review by Anticoagulation Clinical Pharmacist for two variables: - Baseline INR drawn within 24 hours of initiating Warfarin therapy - Dosing regimen for Warfarin followed Protocol May 7 th reminder letter to inpatient Pharmacy staff regarding need for baseline INR prior to starting anticoagulant therapy. Noted improvement in compliance in the following months. A review of Adverse Drug Reports (ADR) is reviewed for any anticoagulation protocol by the Clinical Pharmacists. Plan for anticoagulant patient s transition to home next steps are occurring in the 4 th Quarter 2009 with a paper Coumadin Clinic Referral specific form that will be developed into an ereferral appointment window in the electronic LCR systems. IT plans the build in the 4 th quarter M. Gray to screen requests. September % (11/13) Med Surg Nursing Documentation Patient Education on Warfarin 5-Key Points Spot check nursing documentation of the required patient instruction on the Warfarin 5- Key teaching points given to each Warfarin patient. 5

6 REDUCE THE RISK OF HEALTH CARE-ASSOCIATED INFECTIONS. Goal 7 NPSG Comply with current WHO or CDC hand hygiene guidelines. Sue Felt Elaine Dekker Kitty Mah % (6541/8148 observations) Target raised to 80% 89% (1420/1588) 83% (1078/1300) July % (312/394) Infection control policies and procedures in place for hand hygiene based on CDC guidelines. A hospital-wide Hand Hygiene Campaign implemented with Unit specific Infection Control Liaisons to assist with hand hygiene education and surveillance. Areas developing performance improvement activities September 2009 are: 6C MD and ED Nursing. NPSG Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. Troy Williams Sue Felt 2008: 100% (2/2) st Quarter: 100% (1/1) All nosocomial infections resulting in death or permanent loss of function are reviewed as sentinel events. NPSG Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care. Lisa Winston Elaine Dekker April 1, 2009 MET July 1, 2009 Implement work plan October 1, 2009 pilot test in at least one clinical unit January 1, 2010 Full implementation elements of performance New 2009 national patient safety goal NPSG , NPSG and NPSG has implementation expectations phased in throughout Full implementation expected January 1, L. Winston presented the Implementation work plans to Quality Council July NPSG Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections. Includes short and long term central venous catheters and peripherally inserted central catheter (PICC) lines. Lisa Winston Piera Wong Kitty Mah April 1, 2009 MET July 1, 2009 Implement work plan October 1, 2009 pilot test in at least one clinical unit January 1, 2010 Full implementation elements of performance Central Line Infection Prevention (CLIP) Task Force developed a checklist incorporating IHI recommended care (bundle) with the Joint Commission and NHSN reporting requirements. Ongoing data collection to comply with required reporting of all central line insertions. 6

7 NPSG Implement best practices for preventing surgical site infections. Lisa Winston Ocean Berg Patty Coggan April 1, 2009 MET July 1, 2009 Implement work plan October 1, 2009 pilot test in at least one clinical unit January 1, 2010 Full implementation elements of performance : Initiation (97%) and selection (95%) of prophylactic antibiotics. 1stQuarter 2009: All SCIP measures at or above 90% compliance. ACCURATELY AND COMPLETELY RECONCILE MEDICATIONS ACROSS THE CONTINUUM OF CARE. Goal 8 Implementation Expectation Responsible Long established SFGH Task Force working on the Core Measure Surgical Care Improvement Project (SCIP), focusing on improving discontinuation of antibiotics within 24 hours of surgery end. Measures include: Appropriate Hair Removal Antibiotic timing Antibiotic selection DVT prophylaxis ordered and given Beta blocker administered peri-op to appropriate patients. Identified clippers need to be obtained for non-or settings for procedures that are performed outside the OR but considered surgical (ICU, 6C, and PICC line nurse). NPSG A process exists for comparing the patient s current medications with those ordered for the patient while under the care of the organization. John Luce Sharon Kotabe Fred Hom Nela Ponferrada Sue Schwartz Lalu Bourey 2 nd Quarter 2008: 90%(192/210) Admission 97% (58/60) Transfer August 2008 focus review of decrease in admission medication rec. in July attributed to new interns. Drill down for services to address individuals. NPSG When a patient is referred to or transferred from one organization to another, the complete and reconciled list of medications is communicated to the next provider of service, and the communication is documented. Alternatively, when a patient leaves the organization s care to go directly to his or her home, the complete and reconciled list of medications is provided to the patient s known primary care provider, the original 3rd Quarter 2008: 90% (34/38) 4th Quarter 2008: 94% (60/64) ER: 89% (17/19) Neurology/Neurosurgery Service: 100% (13/13) Follow up with the Nursing Director from L&D (6C) for action plan for improving compliance. Focus auditing continued in 4 th quarter in PACU, Radiology-CT, with improved compliance from L&D (6C). ** Med Rec task force disbanded and will audit quarterly report results to MUSS two times a year. 7

8 referring provider, or a known next provider of service. Note: When the next provider of service is unknown or when no known formal relationship is planned with a next provider, giving the patient and as needed, the family the list of reconciled medications is sufficient. NPSG When a patient leaves the organization s care, a complete and reconciled list of the patient s medications is provided directly to the patient and, as needed, the family, and the list is explained to the patient and/or family. NPSG In settings where medications are used minimally, or prescribed for a short duration, modified medication reconciliation processes are performed. : 100% (5/5) Discharge medication reconciliation list with patient/family education documented. NA Full Med. Reconciliation done for each patient at SFGH New EP for 2009 Activated a patient education completed box at the bottom of discharge medication reconciliation print out. New EP for 2009 Medication Reconciliation committee deemed SFGH current process working and did not want to change process at this point. REDUCE THE RISK OF PATIENT HARM RESULTING FROM FALLS. Goal 9 NPSG Implement a fall reduction program that includes evaluation of the effectiveness of the program. Peggy Wilson Cindy Johnson 2008 Falls per 1000 pt. days SFGH = 3.17 CalNOC benchmark = Falls with moderate or greater injury per 1000 pt. days SFGH = 0.03 CalNOC benchmark = 0.09 Fall per 1000 pt. days SFGH 3.58 CalNOC benchmark = 2.81 SFGH Policy 6.3 outlines the fall reduction program. SFGH actively participates in the California Nursing Outcomes Coalition assess our fall reduction program by benchmarking our patients fall rate, percentage of patients at fall risk at time of fall, and percentage of patients with fall protocol in place at time of fall against other hospitals within California. July 2008: ER Fall assessment and fall reduction plan Implemented. 8

9 Falls with moderate or greater injury per 1000 pt. days SFGH 0.00 CalNOC benchmark = 0.07 Fall per 1000 pt. days SFGH 4.28 CalNOC benchmark = 2.93 Unit 5A testing hourly rounds also testing other fall prevention and harm reduction methods. Hospital wide, multidisciplinary Fall Committee forming. Goals include defining discipline specific fall reduction assessment and fall reduction role in a hospital policy instead of area specific policy. Falls with moderate or greater injury per 1000 pt. days SFGH 0.17 CalNOC benchmark = 0.08 REDUCE THE RISK OF INFLUENZA AND PNEUMOCOCCAL DISEASE IN INSTITUTIONALIZED OLDER ADULTS. Goal 10 (Disease-Specific Care Certification) Implementation Expectation Responsible NPSG The organization develops and implements protocols for administration of the influenza vaccine. Christine Martin Nela Ponferrada Hospital wide Vaccine Screen Flu 1st Quarter 2009 Vaccine Screen Completed: 79% (877/1116) VIS given to patient: 84% (377446) Document Vaccine Administered in MAR: 80% (183/259) March 31, 2009 end of influenza vaccination protocol for hospitalized patients per SFGH policy. Seasonal Influenza Vaccine available to begin in-patient vaccinations in October Currently, plan to vaccinate outpatients with novel H1N1 vaccine, when available. IC to determine when, and if acute inpatients will be vaccinated with novel H1N1 vaccine. Cur NPSG The organization develops and implements protocols for administration pneumococcus vaccine. Christine Martin Nela Ponferrada Pneumococcal Vaccine Screen Completed: 89% (960/1068) VIS given to patient: 77% (209/276) Document Vaccine Administered Review with staff completing audit tool needed when documenting vaccine administration. 9

10 in MAR: 62% (109/176) NPSG The organization develops and implements protocols to identify new cases of influenza and to manage outbreaks. Sue Felt November 2007: IC Pandemic Influenza Plan Policy approved September 2009: IC continual surveillance shows 2 rapid + influenza cases at SFGH inpatient units treated in the usual manner so far this month. October 2009: IC Committee scheduled to review Pandemic Influenza Plan Policy. Infection Control Policy 2.03 SFGH Pandemic Influenza Plan describes surveillance methodology and outbreak management Disaster Drill enacting Pandemic Flu. Infection Control Policy 3.08 Alphabetical List of Diseases/Condition with Required Precautions lists protocol to manage precautions for influenza patients. ENCOURAGE PATIENTS' ACTIVE INVOLVEMENT IN THEIR OWN CARE AS A PATIENT SAFETY STRATEGY. Goal 13 NPSG Identify ways in which the patient and his or her family can report concerns about safety and encourage them to do so. Troy Williams patients used the Patient concern hotline patient used the Patient concern hotline 2008 Patient Concerns reported to Patient Advocate Top Concerns are: Rude/Unprofessional Behavior 37% (95/259 concerns) Dissatisfied with Care 6% (16/259) Educational poster campaign rolled out in October 2007 to encourage patient s involvement in their care and to emphasize their safety. Patient information handbook includes directions on methods to report concerns at SFGH. Beginning in April 15, 2008, Patients will receive the information booklet in the admission unit. Hospital Policy Patient/Visitor Concern/Grievance Policy describes the process and monitoring plan. Patient Concerns committee meets monthly (previously quarterly) to track concerns/grievances, their response time, and added members in 2009 from the top 5 complaint areas to become part of the 10

11 Prevent Health Care Associated Pressure Ulcers (LTC) Goal 14 Long Wait Times 5% (14/259) committee. June 2009: Action Plans being devised in the units with Patient Concerns. Lost Property action plan includes revision/simplification of forms and system for property documentation on admission. NPSG Assess and periodically reassess each patient s risk for developing a pressure ulcer and take action to address any identified risks. (Applicable to long term care accredited organizations) Alfredo Abarca Margo Dextrase- Cordova Peggy Wilson SFGH MDS pressure ulcer data is benchmarked with State and National base. LTC SFBHC and 4A SNF Pressure Ulcers (15.0% CA State Benchmark) Acute Hospital CALNOC Units: HAPU Stage II Prevalence 5.16% CalNOC benchmark: 2.72% TOTAL HAPU 10 Stage 2 HAPU 7 Stage 3 HAPU 2 Stage 4 HAPU 0 Unstageable HAPU 0 DTI HAPU 1 4A SNF and SFBHC SNF: - Initial skin assessment is documented on the Nursing admission base. - The Braden Scale is used to calculate pressure ulcer development risk. - Weekly summary of skin/wound assessment documented. - Skin assessment submitted monthly - MDS. SFGH Acute Hospital interventions: - Skin assessment on E-nursing documentation - Present on Admission Form for documentation of ulcers under development - Assignment of Pressure Ulcer CNS experts to provide education and tools for nursing staff to implement recommended care - Unit log of patients with pressure ulcers. Follow up / reporting system enhancements for pressure ulcer stage worsening to avert fines from CADPH. - SKIN Bundle Implemented - Focus on Prevention 2nd Quarter 2009 CALNOC Units: HAPU Stage II and Greater CALNOC Hospital Acquired Pressure Ulcer (HAPU) prevalence study conducted on a one day snap shot. Each quarter on this one 11

12 Prevalence 4.12 % CalNOC benchmark: 2.87% day study, every patient in the ICU, Stepdown and Med-Surg units are examined for the presence of pressure ulcers. 194 Patients Examined: TOTAL HAPU 13 Stage 2 HAPU 7 Stage 3 HAPU 0 Stage 4 HAPU 0 Unstageable HAPU 1 DTI HAPU 4 THE ORGANIZATION IDENTIFIES SAFETY RISKS INHERENT IN ITS PATIENT POPULATION. Goal 15 NPSG The organization identifies patients at risk for suicide. Note: this requirement only applies to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals. Grad Greene Janet Kosewic 2008: 99% (1259/1277) screened. 95% (41/43) 41 of 43 had a primary diagnosis that was behavioral or emotional in nature and were appropriately assessed for suicide risk using the suicide assessment form. 4/2002 Adopted P&P 1.19 Assessment and Management of the Potentially Suicidal Patient in a Non-Psychiatric Setting 12/04/2007 Revised P&P 1.19 revised to include the suicide risk assessment screening tool in an algorithm format. SFGH Hospital policy 1.19 implemented. This tool was used in both the outpatient and inpatient setting. 95% (251/269) screened No documentation of need for further assessment. None of those audited screened at suicide risk. September 2009, reviewed documentation of suicide risk screen on admission database with nursing staff. 2nd Quarter % (227/230) screened. None identified at risk. 33 of the 230 had an underlying 12

13 emotional or behavioral diagnosis. IMPROVE RECOGNITION AND RESPONSE TO CHANGES IN A PATIENT S CONDITION Goal 16 NPSG The organization selects a suitable method that enables health care staff members to directly request additional assistance form a specially trained individual(s) when the patient s condition appears to be worsening. Leslie Dubbin 159 MERT calls 0.3% (5/159) Upgraded to Code Blue 0.6% (9/159) Intubated on Unit 0 (0/159) Expired 2nd Quarter MERT calls 0.04% (5/137) Upgraded to Code Blue 0.03% (4/137) Intubated on Unit 0.01% (1/137) Expired SFGH MERT is a 24/7 dedicated team responsible for responding to emergency situations that do not meet code blue criteria, aimed at maintaining patients in a stable clinical condition at their current level of care. MERT Calls analyzed quarterly and reported at the Code Blue Committee. The Organization fulfills the Expectations Set Forth in the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery and Associated Implementation Guidelines UP Conduct a preoperative verification process. Terry Dentoni Invasive Procedures Outside the OR: 2nd Quarter 2009: 99% (340/343) Universal protocol audits done in all procedural areas measuring all three implementation requirement expectations. NPSG Mark the procedure site. Site Marking: : 100% (168/168) NPSG A time-out is performed immediately prior to starting the procedures. Time Out Prior to Start of Procedure : 100% (365/365) 13