Illustrating the cost of poor quality Anticipate questions from leadership when advocating for funds

Transcription

1 August 2009 Vol. 10, No. 8 Illustrating the cost of poor quality Anticipate questions from leadership when advocating for funds As more hospital budgets are cut, it s important for staff members who work in quality and patient safety to understand what points to emphasize when making a case for joining a new initiative, launching a new quality improvement program, or asking for increased resources in the name of patient safety. Additionally, many patient safety officers, nurse managers, and quality improvement specialists are being asked for their expertise in quality initiatives and to illustrate where hospitals can find savings with increased patient safety. Depending on the size of the facility, people in various positions may be in charge of determining how to divvy up the budget or advocate for the best use of existing resources. More often than not, however, that decision will include some involvement from the chief financial IN THIS ISSUE p. 3 Patient safety group uses checklists to address specific issues The group s most recent checklist targets nonconventional medicines. p. 6 National Quality Forum updates medication management Safe Practices Pharmacists presence on leadership team will improve patient care. p. 8 APIC survey shows infection control staff, resources cut Results indicate members are trying to keep up with increasing requirements with less means to do so. p. 10 Patient safety Q&A Read answers to some of your colleagues patient safety related queries. officer (CFO) or other members of the hospital s executive team. Realize that CFOs now are more abreast of the clinical issues and not just a number cruncher as they were 10, 15, or 20 years ago, says John Domansky, CFO at Knoxville (IA) Hospital and Clinics. There s a lot more of a balanced approach now in the CFO world than there was in the past. How to make your case Domansky, who makes financial decisions for a critical access hospital licensed for 25 beds, says he is most interested in programs that will minimize the hospital s risk and thus It s important to be well pays more attention to those prepared. Come with having thought through programs emphasizing a proactive multiple sides of the argument. approach to patient care (e.g., a Cory Reeves bar-coding program for medications to prevent potential medication errors). If a staff member from quality or patient safety presents an idea to him, he stresses that he is interested in the hard facts of why that program is necessary. Make sure they have all their facts, says Domansky. What are we avoiding? What are we saving here? How can we potentially justify this? If it was your money, how would you spend it? Try to anticipate the questions ahead of time. Specifically, he points to data concerning the number of incidences of a specific error and information gained from any root-cause analyses done. It s important to be well prepared, says Cory Reeves, CFO of Gordon Hospital, a 69-bed facility in Calhoun, GA, owned by Adventist Health System. > continued on p. 2

2 Page 2 Briefings on Patient Safety August 2009 Illustrating the cost < continued from p. 1 Come with having thought through multiple sides of the argument so that they can talk through and show that they have thought through all that that entails, the value added. Reeves encourages staff members to know what the consequences to the hospital will be for carrying through with an initiative or not going through with it. He says it s apparent to him and other members of the leadership team when someone has not anticipated these questions and prepared answers for them. During the presentation, whatever the topic, Reeves says he prefers to be briefed on the topic at a higher level so he can then ask more detailed questions about the points he is interested in. Editorial Advisory Board Briefings on Patient Safety David M. Benjamin, PhD Adjunct Assistant Professor Department of Pharmacology & Experimental Therapeutics Tufts University School of Medicine Boston, MA Steven W. Bryant Vice President and Managing Director Accreditation Services The Greeley Company Marblehead, MA Sue Dill Calloway, RN, JD Director of Hospital Risk Management OHIC Insurance Company Columbus, OH Wendy Fisher, RN Patient Education Coordinator A.O. Fox Memorial Hospital Oneonta, NY Patricia Gilroy, MSN, MBA Clinical Patient Safety Coordinator Alfred I. dupont Hospital for Children Wilmington, DE Gayla J. Jackson, RN, BSN Nurse Manager Mount Auburn Hospital Cambridge, MA Group Publisher: Emily Sheahan, esheahan@hcpro.com Managing Editor: Heather Comak, hcomak@hcpro.com 781/ , Ext Editorial Assistant: Sarah Kearns, skearns@hcpro.com William N. Kelly, PharmD Professor Mercer University School of Pharmacy Atlanta, GA Tim O Kelly Risk Manager Deaconess Hospital Oklahoma City, OK Patricia Pejakovich, RN, BSN, MPA, CPHQ, CSHA Senior Consultant The Greeley Company Marblehead, MA Ken Rohde Senior Consultant The Greeley Company Marblehead, MA Dennis Wallace, DABRM Consultant Medical Risk Management Associates Bradford Wiley Patient Safety Manager Naval Hospital Great Lakes Great Lakes, IL Briefings on Patient Safety (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $399/year. Briefings on Patient Safety, P.O. Box 1168, Marblehead, MA Copyright 2009 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our Web site at www. hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of BOPS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. BOPS is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. I would suggest you always start out at a very high level and allow them to ask questions, to dig down deeper, and be prepared to answer those, Reeves says. I would say something short to get their attention, and if they continue to want more, you re prepared to give more. Don t forget to relate it to costs Be thinking of the financial effect as well as patient safety and satisfaction. Give to-the-point financial [analysis] especially if it s a positive financial impact. That will get their attention, and they ll want to know more and how that s going to happen, says Reeves. Hospital leaders making decisions about which new initiatives to take on each year must prioritize, often seeing countless projects that could potentially keep patients safer. One hospital leader, John Kane, vice president for quality and patient safety at Catholic Health in Buffalo, NY, cautions those pitching initiative ideas as the right thing to do as the sole reason for taking them on. Don t hinge your whole pitch on just the right thing to do, says Kane. There [are] so many right things to do. It s a given that patient-centered care is the right thing to do, but you don t need to make the assumption that quality always costs more. Kane recommends tailoring a proposal focusing on the dark green dollars at stake. This term, being popularized by the IHI, refers to money attributed directly to the bottom line. In the past, it was not the responsibility of professionals in quality and patient safety to make this connection. However, making this jump now is becoming easier. As reform is coming down the line and it s really centered on cost reduction, as well as waste reduction, we re finding issues that give you strong motivation to go out there and try and figure out how you can get a return on investment through quality, says Kane. By focusing on safety within the organization, it is possible to reduce costs, he says. n

3 August 2009 Briefings on Patient Safety Page 3 Group develops checklists to promote patient safety Community of Competence brings industry minds together Ensuring patient safety and education are two of the most important tasks staff members in healthcare facilities must complete during a patient s stay. Also, making sure that the patient s family is well educated helps keep the patient safe even after he or she has left the facility. The concept of patient safety is nothing new to Matthew Mireles, PhD, MPH, president and CEO of Community Medical Foundation for Patient Safety ( CMFPS) in Bellaire, TX, who has been working to enhance the level of patient safety programs hospitals offer their patients. CMFPS is a learning organization that works to promote education within healthcare facilities. Mireles comes from an aviation background, in which checklists are extremely important. He used his knowledge of checklists, along with help from Elizabeth A. Smith, PhD, founder and chair, and Jerry Miller, PhD, vice president for research, to conduct research on the use of checklists to enhance patient care and safety in hospitals. Checklists geared toward patients and families Mireles, Smith, and Miller began their research by forming a community of nurses and using their expertise to focus CMFPS s efforts. The group discovered that one of the greatest concerns regarding patient care was the lack of preparedness patients exhibited when they came to their appointments. The nurses said patients sometimes forgot important medications or previous surgeries while going over their medical histories and often became stressed. In other cases, language barriers made communication between patients and nurses difficult. With this information, a small group of researchers determined a simple way to solicit all the information communicated into a checklist. Someone suggested anatomical figures for patients to indicate problems on their body would be better than trying to describe the problem in writing, says Mireles. After many suggestions from the nurses and several drafts fine-tuning content and language, the first finalized checklist of the more than 20 now offered by CM- FPS became the Patient Safety Checklist for a Medical Appointment. In addition to the content included in the checklist, the form has an illustration of a human body, which patients can use to identify the location of their pain. The checklist is two pages and must be filled out before the patient s next visit. A version of this checklist can be downloaded at We want to teach individuals, but at the same time, we are trying to emphasize preventing mistakes, especially ones that the patient and family can identify, says Mireles. The backbone to patient safety programs During the checklist drafting process, the Community of Competence (CC) plays a major role in research and development. The CC was developed and trademarked by Smith to help showcase the importance of patient safety and address the industry s complex problems. Community of Competence is a way to bring people together, says Smith. Members are selected based on their skills, abilities, knowledge, experience, and demonstrated competencies and are only asked to lead when their expertise is required. The CC is made up of more than 100 individuals with various backgrounds and experiences who strive to addresses complex problems from a systems approach, says Mireles. To help embody the ideas of the CC and bring the trademark into practice, CMFPS developed CARE, an acronym in which each letter stands for a principle. Mireles breaks down CARE into the following: Community. The CC first builds a community of an individual group, such as healthcare practitioners or nurses in one area that need training, so that it is dynamic and adaptive. > continued on p. 4

4 Page 4 Briefings on Patient Safety August 2009 Checklists < continued from p. 3 Awareness. The CC provides accurate information to members of its community so they can use and build knowledge and increase their practice toward patient safety. Responsibility. This entails personal accountability, in which everybody works together and takes responsibility for some of the failures as well as solutions. Empowerment. The CC provides the tools and begins to empower people to actively participate in the healthcare system. CMFPS continually asks the CC for help to research and draft new checklists as new patient safety issues arise and need to be addressed. The other checklists developed by CMFPS use a similar process during creation, regardless of the topic. First, the group studies a specific topic to determine the relevance to patient safety, then a research group is requested from the CC. A draft of the checklist is then circulated through the CC and the language specialist. Drafts are presented to a focus group, where modifications are made before a final draft is accepted and published. Unused and expired medications addressed in checklist Other checklists the CC helped develop and that CMFPS offers to hospitals include: Fall prevention at the hospital and/or home Basic security at the hospital Medication safety at the pharmacy The most recent checklist published by CMFPS is about using nonconventional medicines. This checklist came after Mireles, Smith, and Miller conducted research and developed a national registry of unused and expired medications (UEM) with the help of the Maine Benzodiazepine Study Group, the Northeast Occupational Exchange, and the University of Maine Center for Aging. It is a national epidemic that no one knew much about, and for many reasons, there are a lot of medicines stockpiled in cabinets across the country, says Miller. Gathering data from California and Maine, the registry determined that approximately 40% 50% of medicines found in cabinets were not used because patients had stopped taking them. From the data in our National Unused and Expired Meds Registry, we were detecting increasing use of alternative and complementary medicines, says Mireles. Samples from California indicated a huge variety of nonconventional items being returned. CMFPS developed the Using Nonconventional Medicines checklist because it was concerned about how these items were used in conjunction with or as a replacement for conventional treatments, says Mireles. By using CC and CARE we were able to bring the experts to the table, and we developed the checklist to help improve safe medicine practice, he says. To promote and raise awareness of the UEM Registry, CMFPS introduced the Get Rid of Unused Pharmaceuticals (GROUP) Program. The purpose of GROUP is to raise awareness about the dangers of UEMs and assist individuals and organizations in planning and implementing a take-back program to safely and legally collect and dispose of UEMs. (See the Get Rid of Our Unused Pharmaceuticals [GROUP] medicine return form on p. 5. Contact CMFPS through its Web site for instruction on how to use this form at your facility.) CMFPS continues to address the growing issue of UEMs in the home and hospitals by encompassing all the programs it has developed. The CC is the underlying theory and foundation of what we are doing, says Mireles. CARE is the mechanism to carry out CC, and the Patient Safety Checklist is an example of a simple CARE program. n

5 August 2009 Briefings on Patient Safety Page 5 Get Rid of Our Unused Pharmaceuticals (GROUP) medicine return form Source: Community Medical Foundation for Patient Safety. Reprinted with permission.

6 Page 6 Briefings on Patient Safety August 2009 Medication safety: A complex puzzle Safe Practices call for increased accountability for pharmacy leaders The National Quality Forum (NQF) included modifications to the medication management chapter in its Safe Practices for Better Healthcare 2009 Update. By combining four existing practices into one, the NQF has called for increased leadership and accountability on the part of hospital pharmacists. Medication management has been a part of the NQF s Safe Practices since they were released in Safe Practices 17 and 18 concern medication safety. I can t think of one area that is more complicated to try and hit the right balance of, said Peter B. Angood, MD, FRCS(C), FACS, FCCM, senior advisor to the NQF on patient safety and former vice president and chief patient safety officer at The Joint Commission. Angood spoke during the June 18 Webinar Medication Safety: Complex Issues for All, hosted by the NQF and Texas Medical Institute of Technology. The difficulty comes with the fact that these are common problems but highly complex in terms of finding solutions, Angood said, adding that many organizations struggle with crafting policies that encourage change in the medication management process. The statistics are well known, yet still shocking: 1.5 million people are harmed each year due to medical errors. In hospitals, about one medication error per patient is made each day. Michael Cohen, RPh, MS, ScD, president of the Institute for Safe Medication Practices (ISMP), which assists Pennsylvania with its mandatory incident reporting system, said that 26% of the state s reported errors were medication errors. In the past 10 years, many efforts have been made to improve medication safety, said Cohen. Beginning with the Institute of Medicine s To Err is Human in 1999 and including the original publication of NQF s Safe Practices, the subsequent updates, and The Joint Commission s Sentinel Event Alerts concerning medication errors, the field has learned a lot about why medication errors occur. It s something we ve preached almost from day one that is the true need to be proactive and not wait for incidents to occur, said Cohen of the ISMP s efforts. He highlighted progress that has come out of collaboration among patient safety groups and learning from mistakes and areas that the healthcare industry still needs to improve on. Communication problems with drug information often lead to medication errors. The field has adapted by highlighting medications that look and sound alike, and the pharmaceutical industry has responded by developing drug names that are not similar to others. Our FDA actually requires that names of drugs being developed by the pharma companies, before they can even apply with their new drug application, they actually have to be tested now by practitioners, said Cohen. We ve begun to see fewer of these drug name pairs that wind up needing a name change. Other common communication errors relate to abbreviations and dose designations, misunderstood or omitted medication suffixes, and differences in how the drug is referred to in international, laboratory, and over-the-counter settings. Healthcare has created some successful fixes to prevent medication errors but needs to be more vigilant about using them. These include: Encouraging the use of tall man lettering with medications that look or sound alike as a means of differentiating when written out Ensuring a read-back of verbal medication orders, versus a repeat-back, so staff members can doublecheck their actions Communicating with pharmaceutical vendors about the need to modify look-alike packaging Standardizing drug concentrations (avoiding use of confusing concentrations, such as 20mg/ml vs. 100mg/5ml, decreases the likelihood of a medication error) Cohen also emphasized the need for hospitals to get patients involved with their medication safety. The ISMP

7 August 2009 Briefings on Patient Safety Page 7 created a Web site for the general public in 2008 to inform patients how they can ensure that their hospital stays are safe. It hopes hospitals will publicize the site ( with their patients to add another level of patient safety. Increased leadership by pharmacists to prevent medication errors Pharmacists should have a greater presence on the leadership team to help navigate the increasingly complicated world of medication management, said Mary Andrawis, PharmD, MPH, director of clinical guidelines and quality improvement at the American Society of Health-System Pharmacists. To ensure that the existing practices to prevent medication errors and develop new ones continue, pharmacists will be an important piece of the puzzle. Literature shows that when pharmacists are involved in care, the result is improved patient care, fewer adverse events, and reduced costs, said Andrawis, speaking about Safe Practice 18. But in order for that full benefit to be realized, it s really important that those pharmacists be given appropriate authority and, consequently, that they continue to take accountability for patient outcomes. Greater integration of pharmacists with the healthcare team not only helps the organization provide more efficient care, but, more importantly, increases patient safety because of greater pharmacist availability to be involved in the decision-making associated with care, said Andrawis. She presented steps facilities can take to boost medication safety: Open the lines of communication between the leadership team and the hospital s pharmacists. Pharmacists want to have a greater role in decisionmaking and can also best explain how medication management can lower the facility s costs, Andrawis said. She gave the example of a new service opening up within the hospital. It s really the pharmacy leader that can best anticipate any disruptions or changes that might [affect] the medication use system from other decisions that are made, she said. Create a medication safety committee. Led by a pharmacist, this committee can review errors, perform root-cause analyses related to medication errors, and brainstorm how to plug gaps in the medication system. This group should also be involved with any WalkRounds that take place, said Andrawis. Make sure pharmacists are involved in technology planning and implementation. Today, many types of technology are used to manage medications in the hospital, including smart pumps, bar coding, and computer physician order entry. I really believe the results could just be catastrophic if the technology is not planned for adequately and implemented safely, said Andrawis. Include a pharmacist on the clinical team. Instead of referring to pharmacists at certain stages of the process, Andrawis encouraged hospitals to consider making the pharmacist part of the team, much like the nurse, doctor, and specialists. Doing so eliminates delays in care, promotes collaboration and better decision-making for each patient s care, and encourages a sense of shared responsibility for each patient, said Andrawis. n Join our free Patient Safety Talk group! Share ideas, policies, checklists, monitoring tools, and get helpful advice from your colleagues when you subscribe to Patient Safety Talk for free. Once you sign up, you ll receive messages from your peers across the country as they discuss the hottest patient safety topics of the day. Recent topics include: Rapid response teams Patient flow Bed entrapments Insulin storage Pressure sores Surgical site Hand hygiene marking Visit index.cfm to subscribe today!

8 Page 8 Briefings on Patient Safety August 2009 Survey: Budget cuts lead to diminished IC staff, resources A survey conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) found that 41% of facilities in the United States have reduced their infection prevention program budgets. APIC rolled out the survey in March after hearing anecdotal evidence from its members that hospitals were cutting budgets and personnel from infection control programs to save money, mostly due to the declining economy. Nearly 2,000 of the group s members responded, and APIC released the results in June, confirming that many facilities are struggling to address shrinking budgets as they try to make infection control and prevention a top priority. This is a problem because we can t protect patients from healthcare-associated infections [HAI] without adequate numbers of properly trained professionals, Christine Nutty, RN, MSN, CIC, president of APIC, said during the group s annual conference in June. We can t provide cutting-edge care without access to the latest science and technology. The following are some of the survey findings: One-third of survey respondents felt that budget cuts had impeded their ability to prevent infections. 25% of respondents said they had to decrease surveillance activities concerning infections. 45% of respondents said they are not receiving the same level of support as in the past to attend industry meetings that keep infection preventionists up to date on the latest standards and practices. About the same number of respondents also said they were unable to attend meetings within their own facilities and took part in fewer rounds. 38% of respondents said they do not spend as much time educating other staff members and patients about infection control practices. Almost two-thirds of respondents have one or less than one full-time equivalent working in infection prevention, and 59% said they do not have anyone working in clerical support. 20% of respondents use data mining software at their facilities. Overall, the survey showed that APIC members feel they are stretched thin trying to keep up with the increasing number of requirements that have been released in the past several years. These include readying for compliance with The Joint Commission s National Patient Safety Goals for infection control that take effect in January 2010 and keeping up with reporting requirements on state and national levels in an effort to be more transparent. Additionally, infection preventionists must keep up with these requirements with fewer staff members and budgetary resources. The lack of data mining systems in most facilities means infection preventionists must perform manually and on their own time much of the work these systems would do automatically, said Nutty. Instead of spending time on patient floors, educating fellow staff members, and helping keep patients safe, infection preventionists are more often behind their desks. Clearly, healthcare executives need to understand that while investing in infection prevention not only saves lives, it saves hospitals money, said Nutty. While cuts in staff, training, and technology may ease budgets in the short term, the effect of increasing infections will erode the bottom line over time, not to mention cause needless pain, suffering, and debt. The business case for infection prevention To get the message across to hospital leaders making the budgetary decisions that infection control is not something to be overlooked, Denise Murphy, RN, MPH, CIC, vice president for patient safety and quality at Main Line Health System in Pennsylvania, recommended starting with the cold hard financial facts. In addition to the normal patient care delivered, the following costs are associated with specific HAIs:

9 August 2009 Briefings on Patient Safety Page 9 $25,000 per surgical site infection $36,400 per bloodstream infection $10,000 per case of ventilated pneumonia $1,000 per urinary tract infection Most of these are included on CMS list of no-pay conditions. The other side of the business case chief financial officers are watching is the number of extra days patients must spend in the hospital recovering from an HAI, said Murphy. This is because not only do patients with HAIs cost the facility extra money for their care, but they prevent new patients from being admitted. Flow is probably the biggest operational focus that the chief operating officer will have, said Murphy. Patients that come through into new beds are bringing new reimbursement. She also noted that a backup in the ICU due to HAIs will limit the number of surgeries a hospital can schedule. Surgeries are another form of reimbursement hospitals may miss out on. The reason money for stronger infection control and prevention programs is not always available is because of the many competing priorities hospital leaders have to consider. Just connecting the dots in order for infection preventionists to better demonstrate their value to their executive team is important, said Murphy. But beyond that, we as infection preventionists have to stop preaching to the choir and talking to our infection prevention and control committees this information must get in front of the executive team. If this money could fund more infection prevention staff members, clerical staff members, technological resources, and educational opportunities for the infection control department, even more money would be saved down the line, said Murphy. For example, Nutty pointed out the effect investment in a data mining system would have on a hospital. The reason facilities don t want to invest in data mining which would really improve the quality of investigating, doing surveillance, and being able to report in real time is because of the cost of data mining, said Nutty. They re looking at the cost up front instead of the entire cost at savings in lives and financial. It s important to keep in mind the real reason for paying more attention to infection prevention when engaging leaders. Although we re talking about the business case here, the most important bottom line is how many people die from these infections, said Murphy. n Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving BOPS, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at 800/ BOPS Subscriber Services Coupon Start my subscription to BOPS immediately. Options No. of issues Cost Shipping Total Electronic 12 issues $399 (BOPSE) N/A Print & Electronic 12 issues of each $399 (BOPSPE) $24.00 Order online at Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total For discount bulk rates, call toll-free at 888/ *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV. State that taxes products only: AZ. Please include $27.00 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Discover Signature (Required for authorization) Card # Expires (Your credit card bill will reflect a charge to HCPro, the publisher of BOPS.) Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web:

10 Page 10 Briefings on Patient Safety August 2009 Patient safety Q&A Editor s note: The following column answers some recent questions on Patient Safety Talk, an HCPro listserv that addresses many of the topics covered in BOPS. This month s questions are answered by Gayle Bielanski, RN, BS, CPHQ, CSHA, consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. How should our hospital handle unlabeled patient medications that are brought into the facility? What if there is no family member to send the medications home with? All home medications brought in by the patient need to be returned home as soon as possible. With medication reconciliation, it may be necessary to identify the medications so the healthcare team can determine what was taken by the patient prior to admission. In this case, the medications will need to be sent to the pharmacist to determine what they are. Once you have identified and documented the medication on the medication reconciliation form, they must return home with the patient s family. If the family is not present, the pharmacy should hold on to the medications and return them to the patient upon discharge or to the patient s family when they come to the facility. Home medications need to be under the control of the pharmacy and should not remain on the nursing unit. If the medications cannot be identified, they should be destroyed by the pharmacy to prevent the patient from taking unidentified medications. What should be charted in the medical record when a medication error occurs? When charting a medication error, only the facts should be documented. For example, Lasix 10 mg given at 2 p.m. Dr. Smith notified of increase in dose. Patient s vital signs monitored as per physician s order and remained unchanged and stable. Never mention that an incident report was filled out or that you notified the risk manager. Documentation should only relate to the patient and any adverse effects, avoiding any judgment calls on how the error occurred. This type of information should be documented on the incident report and shared during any investigation into the error. Keep in mind that clinical information is important to communicate to other healthcare workers, but at some point, an attorney may have access to that medical record. What does The Joint Commission consider acceptable for educating patients about hospitalwide hand hygiene practices? What have you seen as successful practice? The Joint Commission requires patient education regarding infection control measures for hand hygiene practices on the day the patient enters the hospital. This education should be given within hours after admission. The Joint Commission does not dictate how organizations accomplish this, leaving that up to each hospital. To be compliant with National Patient Safety Goal 13, where this requirement is located, some hospitals give a hand hygiene pamphlet to patients in their admission packet. This pamphlet explains the importance of hand hygiene and how the hospital complies with the standard. The nurse, upon completing the initial admission assessment, usually reviews the pamphlet and the admission packet with the patient. Documentation by the nurse in the medical record must include the patient s understanding of the information that was given. n Check out our blog! Stay up to date with the most recent patient safety news by visiting the Patient Safety Monitor Blog. You ll find recent updates to national and state legislation. Visit the blog at blogs.hcpro.com/patientsafety.

11 August 2009 Briefings on Patient Safety Page 11 Infection prevention word search Use this word search to familiarize your staff with infection prevention practices. Answers are on p. 12. Adverse outcome Hand hygiene Leadership Monitoring Resources Surveillance Technology Tracking Zero tolerance

12 Page 12 Briefings on Patient Safety August National Patient Safety Goals to be announced in October In early June, The Joint Commission announced that it will release the 2010 National Patient Safety Goals (NPSG) this October. In the past, the accreditor has released any changes and additions to the NPSGs during the summer of the previous year. However, it announced earlier this year that the NPSGs would undergo some major changes and that there would be no new NPSGs for 2010 with which hospitals will have to comply. The Joint Commission and the Patient Safety Advisory Group, which is involved in the development of the NPSGs on an annual basis, decided earlier this year that, based on feedback from the field, 2009 was the year to substantially review the NPSGs. Last year, The Joint Commission began the Standards Improvement Initiative (SII), which included a yearlong assessment of the standards and solicitation of feedback from the field and experts. In reviewing the NPSGs, The Joint Commission employed the same methods it used during its SII. The Joint Commission posted the proposed 2010 NPSGs to its Web site May 12 and opened them up for a six-week field review, which concluded at the end of June. The proposed 2010 NPSGs represent significant changes from the 2009 NPSGs. Many existing NPSGs are suggested to be moved to the Joint Commission s general standards. These include: NPSG , which requires a read-back of verbal or telephone orders NPSG , which requires a standardized list of do-not-use symbols, dose designations, abbreviations, and acronyms NPSG , which requires a standardized method for handoff communication NPSG , which requires the creation and review of a list of look-alike/soundalike drugs NPSG , which requires the labeling of all medications, medication containers, and other solutions NPSG , which requires facilities to have a fall reduction program NPSG , which requires the hospital have a way for caregivers to request additional assistance from specialized caregivers when they are concerned about a patient Additionally, the NPSGs concerning critical tests and critical results, medication reconciliation, and the Universal Protocol all have substantial proposed changes. Overall, these goals have fewer elements of performance associated with them and more freedom is given to hospitals to decide on their own procedures. Earlier this year, The Joint Commission announced that as of January 1, 2009, it would continue to survey organizations on their medication reconciliation processes, but any findings would not be factored into the accreditation decision. Look for continuing coverage of the 2010 NPSGs in upcoming issues of Briefings on Patient Safety. n Answers (from p. 11)