High 5s Project: Action on Patient Safety SOP Flow Charts 20 th International Forum on Quality and Safety in Healthcare 21-24 April 2015 London, UK
Performance of Correct Procedure at Correct Body Site This flow diagram is not intended to represent the entire preoperative preparation process. Only steps relating to the prevention of wrong site, wrong procedure, or wrong patient surgery are presented. Phase I: Diagnosis Medical history & physical exam Steps that must be checked off in the preoperative verification Check List are indicated by a red-outlined box. Additional tests needed? A Two identifiers used to identify the patient prior to testing; to label specimen containers, images, slides, tracings, etc.; and to identify reports of all tests. Lab tests Imaging studies ECG, EMG, etc. Biopsy Specimen containers labelled in presence of patient: 2 IDs Imaging studies labelled directly on the image: patient, projection, side Other studies labelled directly on the tracing, image, etc: 2 IDs, side Microscopic studies labelled directly on the slide: 2 IDs, site/side A Test results reported timely to responsible practitioner. Verbal/telephone reports - Is surgery or other invasive procedure req d? Conduct informed consent process: Inform patient & family about options, risks, etc. Obtain & document consent for procedure including two patient identifiers, full name of procedure, site, anesthesia plan or preferences Proceed with nonoperative treatment plan Mark surgical site now? Surgeon or qualified designee marks site. Use indelible marker. Patient confirms site. Go to Phase II: Pre-operative planning Source: Action on Patient Safety (High 5s) Correct Site Surgery, Implementation Guide, Version 3.4; 9/5/14
Preoperative preparation as it relates to Correct Site Surgery, Phases II & III: Phase II: Preoperative Planning Schedule surgery: 2 patient identifiers Full name of procedure Side, level, digit, etc. (no abbreviations) Special patient-related factors Special equipment; implants; Request for sedation/anesthesia Was surgery scheduled by telephone? Initiate preoperative verification checklist Read back details of surgical booking or obtain written, printed, or electronic copy of full details. Access H&P, test reports (verify correct pt ID on all) Create medical record for current episode of care. Access prior medical records Is additional pre-op testing Phase III: Pre-op visit to surgical/procedural facility Will anesthesia, sedation, stand - by be used? Conduct additional preop testing with appropriate identification, labeling, etc. Reports in record. Pre-operative nursing assessment, including complete list of current meds. Verify informed consent Surgical nursing plan in Pre-anesthesia assessment. Anesthesia plan in record. Has the surgical site been marked? Is the surgeon available to mark the site? Site marking at or before this time is preferred. Surgeon or qualified designee marks site. Use indelible marker. Patient confirms site. Go to Phase IV: Day of Surgery Source: Action on Patient Safety (High 5s) Correct Site Surgery, Implementation Guide, Version 3.4; 9/5/14
Preoperative preparation as it relates to Correct Site Surgery, Phases IV & V: Phase IV: Day of Surgery On arrival, confirm pt identity (2 IDs). Review procedure & site with patient. Affix identification band to patient. Obtain medical record. Verify all relevant entries, including the informed consent document are present and properly identified for the correct patient. Phase V: Pre-op prep/holding Has surgical site been marked? Obtain relevant imaging studies. Verify correct patient ID on individual images. Site marking prior to this time is preferred. tify surgeon that site needs to be marked. Surgeon or qualified designee marks site. Use indelible marker. Patient confirms site. Complete other pre-op & pre-anesthesia tasks. Have all other pre-op/preanesthesia tasks been completed? Is the OR ready? Hold patient in preop area until OR is ready. Go to Phase VI: Operating/ procedure room Source: Action on Patient Safety (High 5s) Correct Site Surgery, Implementation Guide, Version 3.4; 9/5/14
Preoperative preparation as it relates to Correct Site Surgery, Phase VI: Phase VI: Operating/ procedure room Display relevant images on view box or display screen Move patient to procedure table. Proceed with induction of anesthesia. Position patient for procedure. Prep & drape (site mark must be visible). Verify correct patient IDs on images. Verify correct orientation of images. Are all members of the surgical team present? tify missing team members that case is ready to start. Ye s Conduct final time out Verify correct patient (2 IDs) Verify procedure Verify site Verify correct position Verify availability of special equipment, implants, etc. Are there any discrepancies, questions,concerns, or uncertainties? Resolve/reconcile any discrepancies, etc. Proceed with Correct surgery Re-verify any items that were questioned or uncertain. Source: Action on Patient Safety (High 5s) Correct Site Surgery, Implementation Guide, Version 3.4; 9/5/14
Assuring Medication Accuracy at Transitions in Care: Medication Reconciliation Flow Charts of the Medication Reconciliation Process Medication Reconciliation Process Flow Map Admission to Healthcare Facility Best Possible Medication History (BPMH) Compare Admission Medication Orders (AMOs) Discrepancies Identified IMPROVE WITH: Quality BPMH and medication reconciliation process further action required at admission Intentional Discrepancy Ask prescriber if intentional?, Intentional discrepancy Document Reconcile (correct) Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Step I. Creating a Best Possible Medication History (BPMH) on Admission 1 Patient admitted to health care facility for care. Interview patient/family to obtain list of current medications where possible Review with at least one additional source of information including medications/list brought by patient. As appropriate, contact community pharmacist or primary care physician; review documents from referring healthcare facility Create BPMH using a a systematic process && document on standardized document on form standardized OR compare form the OR BPMH compare to admission the BPMH orders to to admission identify and orders resolve to identify discrepancies and resolve discrepancies Post BPMH in patient s medical record. Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Step II a. Medication Reconciliation at Admission (Proactive Model) Create BPMH (Step I) Use BPMH to write admission orders. Prescriber will make a decision to continue, hold, modify, or discontinue each medication on the BPMH. Implement initial admission medication orders Step II b. Medication Reconciliation at Admission (Retroactive Model) Initial admission medication orders written Compare initial admission medication orders with BPMH Are there any discrepanci Were the discrepanci es Reconcile discrepancies & revise initial Document intention in patient s health record Implement initial admission medication orders Ensure both MAR & BPMH are available in the patient s medical record. Create current medication administration record (MAR). Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Step III. Medication Reconciliation at Internal Transfer To be implemented for transfers from the ED where orders need to be re-written as per hospital policy or when transferred from a different level of care e.g. intensive care unit to a general ward. Is the patient being transferred to a new, unit, service, health care team or level of care where orders Are new medication orders being written? Compare new orders with BPMH & current MAR further action required at this time Compare BPMH & current MAR Are there any discrepancies? further action required at this time Are there any medications on the BPMH that Contact prescriber to resolve discrepancies & modify medication orders if necessary Ensure MAR & BPMH are available in patient s medical record. Update current medication administration record (MAR) Implement new or current medication orders Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Step IV. Medication Reconciliation at Discharge To be addressed in later phases of implementation Is the patient being discharged from the facility? For outpatients, is this the end of the current action required action required Physician writes discharge order and prescriptions for any new or changed medications to be taken Compare BPMH & previous 24 hour MAR with discharge prescriptions; may also compare with discharge order, discharge plan of care or discharge summary if applicable Contact physician to resolve discrepancies; modify discharge prescriptions and/or instructions as needed creating a best possible medication discharge plan (BPMDP) Are there any discrepancies? Communicate the BPMDP to: Patient Community pharmacy Primary care Physician Other healthcare facility or services Evaluate & account for: New medications Discontinued medications Adjusted medications Unchanged medications to be continued Medications held in hospital n-formulary/formulary adjustments New medications started on discharge Additional comments as appropriate Discharge Patient This communication should include: New medications Discontinued medications Adjusted medications Unchanged medications to be continued Medications held in hospital n-formulary/formulary adjustments New medications started on discharge Additional comments as appropriate Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Step V. Patient Involvement Post-Discharge & Prior to Next Episode of Care Best possible medication discharge plan (BPMDP) & instructions received by patient upon discharge from episode of care Patient/family develops and maintains a complete list of the medications they are currently taking in consultation with Provide list to caregiver upon entry into health care organization. Community outreach program to encourage med list development & maintenance by patient/family, community pharmacist, primary care physician and/or healthcare team, alternate healthcare facility Source: Action on Patient Safety (WHO High5s) Medication Reconciliation Implementation Guide, Version 4; October 2014
Managing Concentrated Injectable Medicines: Concentrated Injectables